Adult Health Developed by Dare Domico, RN, DSN Revised by Jill Ray
Integumentary Disorders
Practice Question 1 A client returns the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion? 1. Melanoma is the most common type of skin cancer. 2. Melanoma is often precipitated by pruritus. 3. Melanoma is highly metastatic 4. Melanoma is characterized by local invasion
Practice Question 1 A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion? 1. Melanoma is the most common type of skin cancer. Basal cell is the most common type. 2. Melanoma is often precipitated by pruritus. Can be part of the assessment findings for skin cancer. 3. Melanoma is highly metastatic – survival dependent upon early dx and tx. 4. Melanoma is characterized by local invasion can metastasize to the brain, lungs, bone, liver, skin….
Practice Question 2 Which lesion best represents Basal Cell Cancer? 2. 1. 3. 4.
Practice Question 2 Which lesion best represents Basal Cell Cancer? 1. Basal Cell 2. Mole 4. Melanoma 3. Squamous Cell
Basal Cell: v Waxy border v Papule v Red, central crater v Metastasis rare Squamous Cell: v oozing, bleeding, crusting lesion v Potentially metastatic v Larger tumors higher risk metastasis. Melanoma: v. Irregular, circular, bordered lesion v. Hues of tan, black, blue v. Rapid infiltration into tissue, rapid metastasis.
Practice Question 3 A client has a superficial skin tear to the arm. The nurse applies which best type of dressing? 1. Dry sterile dressing 2. Wet-to-dry dressing 3. Gelfoam sponge dressing 4. Semipermeable film dressing
A client has a superficial skin tear to the arm. The nurse applies which best type of dressing? 1. Dry sterile dressing stick to the wound 2. Wet-to-dry dressing not necessary 3. Gelfoam sponge dressing type of enzyme dressing used to tx necrotic tissue 4. Semipermeable film dressing Op-site, duoderm. Allow tissues to heal underneath.
Practice Question 4 A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate? 1. Give the client small glasses of clear liquids. 2. Keep the client NPO. 3. Allow the client to have full liquids. 4 Order the client a full meal with extra liquids.
Practice Question 4 A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate? 1. Give the client small glasses of clear liquids. 2. Keep the client NPO. Maintain NPO because burn injuries freq. cause paralytic ileus. Fluids could cause vomiting because of the effect of the burn injury on GI fx. Oral care to alleviate thirst is OK 3. Allow the client to have full liquids. 4 Order the client a full meal with extra liquids. Note that 1, 3, and 4 are similar choices.
Practice Question 5 In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile: 1. Tongue blade 2. 4 by 4 gauze pad 3. gloved hand 4. 4 by 4 soaked in sterile saline
In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile: 1. Tongue blade rough surface would be abrasive to the injured skin, and it is too small to be practical for use… 2. 4 by 4 gauze pad the dry gauze pad would stick to the injured skin 3. gloved hand allows for better contact and control of the amt of pressure being applied to the burn area. Allows the nurse to feel the surface blisters without breaking them. 4. 4 by 4 soaked in sterile saline OK – but the gloved hand allows for more precise application and minimal injury to the tissue.
Practice Question 6 A client is NPO and has a NG tube in place after suffering bilateral burns to the legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment? 1. Gastric p. H of 3 2. Presence of hypoactive bowel sounds 3. GI drainage that is guaiac negative 4. Absence of abdominal discomfort
Practice Question 6 A client is NPO and has a NG tube in place after suffering bilateral burns to the legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment? 1. Gastric p. H of 3 gastric p. H should be maintained at 7 or greater using prescribed antacids and histamine h 2 receptor-blocking agents. Lowered p. H in the absence of fd or tube feedings can lead to erosion of the gastric lining and ulcer development. 2. Presence of hypoactive bowel sounds expected as client is NPO and has suffered burn injury 3. GI drainage that is guaiac negative normal finding – means that it is negative for blood 4. Absence of abdominal discomfort WNL
Practice Question 7 A client is admitted to the emergency department following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as 1. Superficial thickness burn 2. Superficial partial thickness 3. Deep partial thickness 4. Full thickness
Practice Question 7 A client is admitted to the emergency department following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as 1. Superficial thickness burn these burns are painful 2. Superficial partial thickness these burns are painful 3. Deep partial thickness wound surface red, dry, with white areas in deeper areas. 4. Full thickness involve epidermis, and some subcutaneous fat. Some nerve endings damaged – may be insensitive to touch with little or no pain.
Superficial Thickness burn ØInjury to the upper third of the dermis – bld supply to dermis is intact. ØMild to sever erythema (pin to red) ØSkin blanches with pressure ØBurn painful, tingling, eased by cooling ØDiscomfort lasts about 48 hrs – heals in 3 -5 days ØNo scarring and skin grafts not required.
Superficial Partial-thickness Burn • Injury deeper into dermis, bld supply reduced • Large blisters may cover an extensive area • Edema present • Mottled pin to red base, broken epidermis, with wet, shiny, weeping surface • Burn painful, sensitive to cold air • Heals 0 -21 days with no scarring, minor pigment changes possible • Grafts may be needed
Deep Partial-thickness Burn
Deep Partial-thickness Burn • Extends into dermis • Blister formation usu not seen because dead tissue is thick and sticks to underlying viable dermis • Wound surface is red and dry with white areas in deeper parts • May/may not blanch, edema is moderate • Con convert to full thickness if complications • Heals in 3 -6 weeks, scar results, skin graft may be necessary
Full-thickness Burn • Involves injury and destruction of the epidermis ad the dermis; wound will not heal by reepithelializaion, grafting may be required • Appears as a dry, hard, leathery eshcar (burn crust or dead tissue that must slough off or be removed form the wound before healing can occur • Appears as a waxy white, deep red, yellow, brown, black • Injured are appears dry • Edema present under eschar • Sensation reduced or absent because of nerve ending damage • Healing takes weeks to months and dependent on adequ bld supply • Must remove eschar and split-or full-thickness skin grafting • Scarring and wound contractures likely
Deep full-thickness • Extends beyond the skin into underlying fascia and tissues, damage to the muscle, bone, tendons • Injured area appears black and sensation is completely absent • Eschar is hard and inelastic • Healing takes months and grafts are requ • Mortality rates are higher for children younger than 4 • Debilitating disorders (cardiac, respiratory, endocrine, renal disorders occur and hinder healing • Mortality rate is higher with preexisting disorder.
Practice Question 8 A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment. ? 1. Urine output of 40 ml/hour. 2. Urine that is pale yellow. 3. Urine specific gravity of 1. 032 4. Urine p. H of 6.
A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment. ? 1. Urine output of 40 ml/hour. 30 ml/hr is WNL, 40 is OK 2. Urine that is pale yellow. Pale urine is normal – would be dark and concentrated if not well hydrated 3. Urine specific gravity of 1. 032 (1. 0161. 022) 4. Urine p. H of 6. OK – urine p. H of 6 is adequate (4. 5 -8 WNL). Do not monitor urine p. H to assess hydration.
Practice Question 9 A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort? 1. Take baths twice daily using a dilute solution of vinegar and water. 2. Avoid the use of astringents on the skin 3. Avoid the use of emollients on the skin 4. Purchase a dehumidifier for the home.
A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort? 1. Take baths twice daily using a dilute solution of vinegar and water. Warm bath or shower per day for 15 -20 min with warm water and a mild soap followed immediately by the application of an emollient to prevent evaporation of water form the hydrated epidermis. 2. Avoid the use of astringents on the skin avoid alcohol, astringents, or other 3. 4. drying agents to the skin. tend to have a drying affect on the skin Avoid the use of emollients on the skin need to incr use of emollients Purchase a dehumidifier for the home. A dehumidifier would further dry room air.
Practice Question 10 The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area? 1. Intact skin 2. Partial-thickness skin loss of the epidermis 3. Deep, crater-like appearance 4. Presence of sinus tracts
Practice Question 10 The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area? 1. Intact skin 2. Partial-thickness skin loss of the epidermis 3. Deep, crater-like appearance 4. Presence of sinus tracts
Classification of Pressure Ulcers I Nonblanchable erythema of the intact skin. II Partial-thickness skin loss involving epidermis and /or dermis. III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. IV Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.
Stage I (no skin loss) Stage II (Shallow crater – involves epidermis and/or dermis)
Stage III (Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia) Stage III or IV
Stage IV Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.
Oncology
Practice Question 11 The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply. 1. Cardiac tamponade 2. Leukopenia 3. Syndrome of inappropriate ADH 4. Hypercalcemia 5. Hypophosphatemia 6. Tumor lysis syndrome
The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply. 1. Cardiac tamponade could result from direct pressure from a tumor, complication from chemo (decr platelets incr chances of hemorrhage) 2. Leukopenia 3. Syndrome of inappropriate ADH tumors can produce, secrete, or stimulate substances that mimic ADH hormone – low serum Na levels result and can lead to seizures, comoa, death 4. Hypercalcemia late manifestation of extensive malignancy 5. Hypophosphatemia 6. Tumor lysis syndrome large quantities of tumor cells are destroyed rapidly. Can lead to renal failure.
Practice Question 12 The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client. 1. Avoid folic acid intake. 2. Increase intake of oral fluids. 3. Report symptoms of dyspnea. 4. Report symptoms of hematuria.
Practice Question 12 The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client? 1. Avoid folic acid intake. 2. Increase intake of oral fluids. 3. Report symptoms of dyspnea. This med can cause cardio toxicity, cardiomyopathy, EKG changes. CHF (dyspnea, tachycardia, peripheral edema) and myocardial toxicity are potential adverse reactions. 4. Report symptoms of hematuria.
Practice Question 13 A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? 1. Avoid any needle sticks in the left arm. 2. Avoid abduction & external rotation of left arm. 3. Begin pendulum arm swings & full ROM immediately. 4. Elevate left arm on pillows to prevent edema. 5. Have all blood pressure readings taken on the right arm. 6. Massage wound site with essential oils once incision has healed.
A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? 1. Avoid any needle sticks in the left arm. 2. Avoid abduction & external rotation of left arm. Gradual abd and ext rotation of the affected arm is encouraged. May be more comfortable elevating the arm. 3. Begin pendulum arm swings & full ROM immediately. These activities are started after the incision has healed. 4. Elevate left arm on pillows to prevent edema. 5. Have all blood pressure readings taken on the right arm. 6. Massage wound site with essential oils once incision has healed. No indication for this
Postoperative Mastectomy • Gradual abduction and external rotation of the affected arm is encouraged. • Avoid activities that might lead to the development of lymphedema • Begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema. • Active exercises, such as pendulum swings and wall climbing are started after the incision has healed
Practice Question 14 A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs 2. Apply antacid coating solutions and viscous lidocaine 3. Brush oral plaques off with a soft toothbrush. 4. Have client swish mouth with weak hydrogen peroxide solution
Practice Question 14 A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs could cause pain 2. Apply antacid coating solutions and viscous lidocaine Antacids, Benadryl, and viscous lidocaine have been mixed in equal proportions to use as a component of oral care. 3. Brush oral plaques off with a soft toothbrush. could cause pain 4. Have client swish mouth with weak hydrogen peroxide solution
Practice Question 15 A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area? 1. Use mild soap and do not rub with abrasive materials. 2. Do not use any lotions on the area being treated. 3. Expose the area to sunshine to maximize healing. 4. Wear clothing and bras that support the area.
A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area? 1. Use mild soap and do not rub with abrasive materials. Skin being tx is fragile and easily damaged. Mild soap and thorough rinsing with warm water. 2. Do not use any lotions on the area being treated. A hydrophilic moisture lotion can be used if the skin becomes dry. 3. Expose the area to sunshine to maximize healing. The area cannot be exposed to sun 4. Wear clothing and bras that support the area. Clothing should be loose and nonbinding.
Practice Question 16 Which of the following is a priority nursing intervention for a client with a vaginal radium implant? 1. Clamp and drain the Foley catheter at intervals. 2. Provide a high residue diet. 3. Place the client in a semiprivate room. 4. Raise the head of the bed no more than 20 degrees.
Which of the following is a priority nursing intervention for a client with a vaginal radium implant? 1. Clamp and drain the Foley catheter at intervals. 2. Provide a high residue diet. Good idea – maintain optimal GI fx. Note that “ 4” is the BEST choice but that this is appro. 3. Place the client in a semiprivate room. No Private room, private bath 4. Raise the head of the bed no more than 20 degrees. Once the implant is in place, important to keep in the exact location. HOB only raised slightly if at all after placement.
Practice Question 17 The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to 1. Call the MD 2. Pick up the implant with gloved hands and flush it down the toilet 3. Reinsert the implant into the vagina immediately 4. Pick up the implant with long handled forceps and place it in a lead container
Practice Question 17 The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to 1. Call the MD yes, but initial action is “ 4” 2. Pick up the implant with gloved hands and flush it down the toilet do not touch the implant 3. Reinsert the implant into the vagina immediately inappro action. 4. Pick up the implant with long handled forceps and place it in a lead container Key word is “initial” action.
Practice Question 18 The nurse is caring for a client experiencing Hematologic toxicity as a result of chemotherapy. The nurse develops a plan of care for the client. The nurse plans to 1. Restrict all visitors 2. Restrict fluid intake 3. Insert an indwelling urinary catheter to prevent skin breakdown 4. Restrict fresh fruits and vegetables in the diet
Practice Question 18 The nurse is caring for a client experiencing Hematologic toxicity as a result of chemotherapy. The nurse develops a plan of care for the client. The nurse plans to 1. Restrict all visitors eliminate this choice because of the term “all”. The client is protected from persons with known infections. 2. restrict fluid intake unrealistic to restrict fluids in chemotherapy client who is at risk for fluid and electrolyte imbalance. Need to encourage fluids. 3. Insert an indwelling urinary catheter to prevent skin breakdown risk of infection, other noninvasive measures can be used if indicated 4. Restrict fresh fruits and vegetables in the diet immunocompromised client needs a lowbacteria diet. Includes avoiding fresh fruits and vegetables and thorough cooking of all foods.
Practice Question 19 The client is diagnosed with benign prostatic hyperplasia and is scheduled for transrectal ultrasound and drawing of a prostate-specific antigen level. The client says to the nurse, “ I can’t remember. Can you tell me again why I need these tests to be done? ” The nurse responds knowing that the tests 1. Help to rule out the presence of cancer 2. Specifically predict the course of benign prostatic hyperplasia 3. Pinpoint the likelihood of developing urinary obstruction 4. Give an indication of whether intermittent selfcatheterization is needed.
The client is diagnosed with benign prostatic hyperplasia and is scheduled for transrectal ultrasound and drawing of a prostate-specific antigen level. The client says to the nurse, “ I can’t remember. Can you tell me again why I need these tests to be done? ” The nurse responds knowing that the tests 1. Help to rule out the presence of cancer 2. Specifically predict the course of benign prostatic hyperplasia 3. Pinpoint the likelihood of developing urinary obstruction 4. Give an indication of whether intermittent selfcatheterization is needed. diagnostic test do not predict the course of a disease – likelihood of developing complications (i. e. obstruction)
Practice Question 20 A nurse is reviewing the lab results of a client with leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets that the client is at risk for 1. Infection 2. Bleeding 3. Anemia 4. Dehydration
Practice Question 20 A nurse is reviewing the lab results of a client with leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets that the client is at risk for 1. Infection 2. Bleeding platelets are low 3. Anemia H/H low 4. Dehydration SG is closer to 1. 0.
Practice Question 21 The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care? 1. Ambulation 3 times daily 2. Monitoring temperature 3. Pad side rails and sharp corners of the bed and furniture 4. Monitoring for pathological fractures
The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care? 1. Ambulation 3 times daily important in the plan of care but not related directly to thrombocytopenia 2. Monitoring temperature monitoring for infection, important esp if dealing with a leukemia pt – not the best choice for a pt with thrombocytopenia. 3. Pad side rails and sharp corners of the bed and furniture thrombocytopenia indicates a decr in number of platelets in circulating blood – client is at risk of bleeding. 4. Monitoring for pathological fractures important in the plan of care but not related directly to thrombocytopenia
Practice Question 22 A nurse is caring for the 25 -year-old client will undergo bilateral orchidectomy for testicular cancer. Which of the following statements by the nurse would be most helpful in exploring the client's concerns about loss of reproductive ability? 1. “Has the doctor told you that you will not be able to have children? ” 2. “You must be sad that you won't be able to have children after surgery. ” 3. “Do you feel that the doctor has told you all you need to know about the upcoming surgery? ” 4. “Share with me any concerns about how this surgery will affect you in the future. ”
Practice Question 22 A nurse is caring for the 25 -year-old client will undergo bilateral orchidectomy for testicular cancer. Which of the following statements by the nurse would be most helpful in exploring the client's concerns about loss of reproductive ability? 1. “Has the doctor told you that you will not be able to have children? ” yes/no 2. “You must be sad that you won't be able to have children after surgery. ” yes/no 3. “Do you feel that the doctor has told you all you need to know about the upcoming surgery? ” yes/no 4. “Share with me any concerns about how this surgery will affect you in the future. ”
Endocrine
Pituitary Gland Hypopituitarism • Decr secretion of: – – • growth hormone, gonadotropic hormones, thyroid-stimulating hormone, adrenocorticotropic hormone, antidiuretic hormone Hyperpituitarism • Incr secretion of – Growth hormone – Other pituitary hormones may also be involved…can see Cushing’s syndrome • – – – – – Assessment: – Obesity (GH, TSH) – Decr CO (GH, ADH) – Infertility, sexual dysfx (gonadotropins, ACTH) – Fatigue, low BP (TSH, ADH, ACTH, GH) • Tx – Emotional support – Hormone replacement – education Assessment • Large hands/feet Thickening /protrusion of the jaw Arthritic changes Visual disturbances Diaphoresis Oily, rough skin Organomegaly Hypertension Dysphagia Deepening of the voice Tx – – Emotional support Frequ skin care Pain management for joint pain Prepare for radiation/hypophysectomy if planned
Syndrome of Inappropriate ADH(SIADH) vs Diabetes Insipidus • Decr secretion of ADH (opposes Diuresis – decre secretion would mean that the body would loose large quantities of fluid via the u/o) • Assessment: – Polyuria (4 -24 L/day), Polydipsia, Dehydration – Inability to concentrate urine (sg 1. 006 or lower) – Fatigue, muscle pain, weakness, h/a – Postural hypotension, tachycardia • Tx: – – – – Monitor v/s and neuro and CV status Safety: postural hypotension Monitor electrolytes Monitor I/O, wt, serum osmolality, urine s. g. Restrict foods, liqu that produce diuresis Diabinese Pitressin, desmopressin acetate Medic alert bracelet SIADH • Incr secretion of ADH (the body would retain fluid) • Assessment: – – – • s/s fluid volume overload LOC changes Wt gain, anorexia, nausea, vomiting Hyponatremia (dilutional) Hypertension, tachycardia Tx – – – – Monitor v/s Safety: altered LOC I/O, daily wt Monitor electrolytes, serum/urine osmolality, Restrict fluid intake Adm diuretics and IV fluids Demeclocycline
Adrenal Gland Addison’s disease • Hyposecretion of adrenal cortex hormones • Assessment: – Lethargy, fatigue, muscle weakness – GI disturbances – Wt loss – Menstrual changes/impotence – Hypoglycemia, hyponatremia – Hyperkalemia – Hypercalcemia – Postural hypotension – Hyperpigmentation of skin • Cushing’s disease • Hypersecr of glucocorticoids • Assessment: – Muscle wasting, weakness – Moon face, buffalo hump – Truncal obesity, thin extremities – Wt gain – Hirsutism (females) – Hyperglycemia, hypernatremia – Hypokalemia, hypocalcemia – Hypertension – Fragile skin that easily bruises – Reddish-purple striae on the abd and upper thighs
Thyroid Gland Hypothyroidism • Decr secretion of T 3 and T 4 • Decr rate of body metabolism • Assessment: – Lethargy – Weakness, muscle aches, paresthesias – Intolerance to cold – Wt gain – Dry skin, hair loss – Bradycardia – Constipation – Generalized puffiness/edema around the eyes and face (myxedema) – Forgetfulness/loss of memory – Menstrual distrubances – Cardiac enlargement, CHF – Perhaps goiter Hyperthyroidism • Incr secre of T 3 and T 4 • Incr rate of body metabolism • Graves’ Disease common cause/Toxic diffuse goiter • Assessment : – – – Enlarged thyroid Palpitations, cardiac dysrhthmias Exophthalmos Hypertension Heat intolerance Diaphoresis Wt loss Diarrhea Smooth, soft skin, hair Nervousness/fine tremors if hands Personality changes such as irritability/agitation/mood swings
Parathyroid Gland Hypoparathyroidism • Decr secr of parathyroid hormone (causes decrease in Ca and incr in phosphorus) • Assessment – s/s of tetany – Hypocalcemia/ hyperphosphatemia – Numbness/tingling in the face – Muscle cramps/abd cramps – Positive Trousseau’s sign (carpal spasm) or Chvostek’s sign (facial spasm) – Hypotension – Anxiety, irritability, depression Hyperparathyroidism • Hypersecr of Parathyroid hormone (incr in Ca levels, decr in phos) • Assessment: – Hypercalcemia, hypophosphatemia – Fatigue, muscle weakness – Skeletal pain/tenderness – Bone deformities/pathological fractures – Anorexia, nausea, vomiting, epigastric pain – Wt loss – Constipation – Hypertension – Cardiac dysrhthmias – Renal stones
Practice Question 23 The ER nurse planning care for a client with a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome knowing that the hyperglycemia results from 1. increased use of glucose 2. increased production of glucose. 3. overproduction of insulin 4. Over hydration
Practice Question 23 The ER nurse planning care for a client with a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome knowing that the hyperglycemia results from 1. increased use of glucose 2. increased production of glucose. Note that the stem asks for the cause of the hyperglycemia 3. overproduction of insulin 4. Over hydration
Diabetic Ketoacidosis vs Hyperglycemic Hyperosmolar Nonketotic Syndrome DKA • Complication of Type I DM • Occurs with severe insulin deficiency • Clinical manifestations: hyperglycemia, dehydration, ketosis, acidosis • Tx: – restore bld volume, – tx dehydration, – tx hyperglycemia, – correct electrolyte imbalance • Monitor potassium levels HHNS • Extreme hyperglycemia without ketosis or acidosis • Occurs most often in individuals with Type II DM • Ketosis and acidosis do not occur • Clinical manifestations: CNS alterations, dehydration or electrolyte loss • Tx: – Similar to DKA – Fluid replacement, correct electrolyte imbalance, – Administer insulin – Rehydration alone may decrease glucose levels
Practice Question 24 The client with diabetes has been instructed in the dietary exchange system. The client ask if bacon is allowed in the diet. Which response is most appropriate? 1. “Bacon is much too high in fat. ” 2. “Bacon is not allowed. ” 3. “One strip of bacon may be eaten if one teaspoon of butter is omitted. ” 4. “Bacon may be eaten if you eliminate one meat item from your diet. ”
Practice Question 24 The client with diabetes has been instructed in the dietary exchange system. The client ask if bacon is allowed in the diet. Which response is most appropriate? 1. “Bacon is much too high in fat. ” 2. “Bacon is not allowed. ” 3. “One strip of bacon may be eaten if one teaspoon of butter is omitted. ” 4. “Bacon may be eaten if you eliminate one meat item from your diet. ”
Practice Question 25 A client with type 1 diabetes reports recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin & exercise? “The best time for me to exercise is 1. in the afternoon. ” 2. after I eat. ” 3. after breakfast. ” 4. after my morning snack. ”
Practice Question 25 A client with type 1 diabetes reports recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin & exercise? “The best time for me to exercise is 1. in the afternoon. ” NPH insulin peaks in 6 -14 hours. 2. after I eat. ” 3. after breakfast. ” 4. after my morning snack. ”
Practice Question 26 A client with type 1 diabetes reports vomiting & diarrhea with no food intake or medications for 36 hours. Which additional statement indicates a need for further teaching? “I need to 1. stop my insulin. ” 2. increase my fluid intake. ” 3. call the physician because of these symptoms. ” 4. monitor my blood glucose every 3 to 4 hours. ”
Practice Question 26 A client with type 1 diabetes reports vomiting & diarrhea with no food intake or medications for 36 hours. Which additional statement indicates a need for further teaching? “I need to 1. stop my insulin. ” Type I DM need to maintain routine schedule of insulin administration unless prescribed otherwise by MD. Note that BG often increases with stress/illness. 2. increase my fluid intake. ” should do this 3. call the physician because of these symptoms. ” should do this 4. monitor my blood glucose every 3 to 4 hours. ” should do this
Practice Question 27 A client with diabetes has a glycosylated hemoglobin A 1 C level of 9%. Based on this test result, the nurse plans to teach the client about the need to 1. avoid infection. 2. take in adequate fluids. 3. prevent hyperglycemia. 4. prevent hypoglycemia.
Practice Question 27 A client with diabetes has a glycosylated hemoglobin A 1 C level of 9%. Based on this test result, the nurse plans to teach the client about the need to 1. avoid infection. 2. take in adequate fluids. 3. prevent hyperglycemia. Goal for pt with DM is less than 7. 5 %. This value provides an estimate of BGL for the prior 3 -4 months. 4. prevent hypoglycemia. Pt without DM value should be 4 -6%.
Practice Question 28 A nurse is providing instructions to a client newly diagnosed with diabetes regarding insulin administration. A mixture of NPH and regular insulin is ordered. Sequence the following steps of this procedure: 1. inject air equal to the amount of NPH insulin into the vial of NPH insulin. 2. inject air equal to the amount of regular insulin into the vial of regular insulin 3. draw up the correct dosage of regular insulin 4. draw up the correct dosage of NPH insulin 1, 2, 3, 4
Practice Question 29 A nurse is providing home care instructions to a client with a diagnosis of Addison’s disease. Which statement by the client indicates a need for further instructions? “I need 1. to wear a Medic Alert bracelet. ” 2. to take daily medications for a limited period of time. ” 3. an increased dose of glucocorticoid medication during stressful minor illnesses. ” 4. to purchase a travel kit that contains cortisone. ”
Practice Question 29 A nurse is providing home care instructions to a client with a diagnosis of Addison’s disease. Which statement by the client indicates a need for further instructions? “I need 1. to wear a Medic Alert bracelet. ” true 2. to take daily medications for a limited period of time. ” chronic disease will take meds from now on… 3. an increased dose of glucocorticoid true medication during stressful minor illnesses. ” 4. to purchase a travel kit that contains cortisone. ” true
Practice Question 30 A client has returned to the unit following a thyroidectomy complaining of tingling sensations around the mouth and in the fingers. The nurse would next assess the results of which serum lab study? 1. Sodium 2. Potassium 3. Calcium 4. Magnesium
Practice Question 30 A client has returned to the unit following a thyroidectomy complaining of tingling sensations around the mouth and in the fingers. The nurse would next assess the results of which serum lab study? 1. Sodium 2. Potassium 3. Calcium because of accidental damage to the parathyroid which regulates CA levels. 4. Magnesium
Practice Question 31 Which medication will the nurse have available for emergency treatment of tetany in the client who has had a thyroidectomy? 1. Calcium chloride 2. Potassium chloride 3. Magnesium sulfate 4. Sodium bicarbonate
Practice Question 31 Which medication will the nurse have available for emergency treatment of tetany in the client who has had a thyroidectomy? 1. Calcium chloride supplemental Ca is indicated if s/s of tetany develop. 2. Potassium chloride 3. Magnesium sulfate 4. Sodium bicarbonate
Practice Question 32 A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order? 1. 2. 3. 4. Place flat with head and neck immobilized. Rectal temps only until discharge. Maintain endotracheal tube for 24 hours. Continuous mist of room air or oxygen.
Practice Question 32 A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order? 1. Place flat with head and neck immobilized. Do not need to immobilize the neck. 2. Rectal temps only until discharge. Oral, axillary temps are OK 3. Maintain endotracheal tube for 24 hours. Not necessarily intubated. 4. Continuous mist of room air or oxygen. Humidity will asst to decr postop inflammation.
Practice Question 33 A nurse is caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase the priority nursing action is to prepare to 1. administer regular insulin IV. 2. administer 5% dextrose IV. 3. correct the acidosis. 4. apply an electrocardiogram monitor.
Practice Question 33 A nurse is caring for a client admitted to the emergency room with diabetic ketoacidosis (DKA). In the acute phase the priority nursing action is to prepare to 1. administer regular insulin IV. 2. administer 5% dextrose IV. 3. correct the acidosis. True 4. apply an electrocardiogram monitor. Probably true
Practice Question 34 A nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse ensures that which medical equipment is at the bedside? 1. Underwater seal chest drainage. 2. Tracheotomy set. 3. Intermittent gastric suction. 4. Cardiac monitor.
Practice Question 34 A nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse ensures that which medical equipment is at the bedside? 1. Underwater seal chest drainage. 2. Tracheotomy set. Surgery very close to trachea. Postop swelling could close the airway and create the need for Tracheostomy. 3. Intermittent gastric suction. 4. Cardiac monitor.
Practice Question 35 The nurse is assessing a client with syndrome of inappropriate antidiuretic hormone (SIADH). What would the nurse expect to find on the laboratory values? 1. Serum sodium=150 m. Eq/L and low urine osmolality. 2. Serum potassium=5 m. Eq/L and low serum osmolality. 3. Serum sodium=120 m. Eq/L and low serum osmolality. 4. Serum potassium=3 m. Eq/L and high serum osmolality.
Practice Question 35 The nurse is assessing a client with syndrome of inappropriate antidiuretic hormone (SIADH). What would the nurse expect to find on the laboratory values? 1. Serum sodium=150 m. Eq/L and low urine osmolality. 2. Serum potassium=5 m. Eq/L and low serum osmolality. 3. Serum sodium=120 m. Eq/L and low serum osmolality. SIADH causes the body to retain water. The serum sodium will be low (dilutional hyponatremia) and the serum osmolality will be low. Note Na levels are 135145. 4. Serum potassium=3 m. Eq/L and high serum osmolality.
Syndrome of Inappropriate ADH (SIADH) • Excessive Antidiuretic Hormone (ADH) is released. • ADH hormone opposes diuresis – which means that water is retained even when the plasma (serum) osmolality is normal. • As a result of extracellular fluid expansion, serum osmolality decreases. • Na levels decline because of the excess fluid volume.
Practice Question 36 A client has been receiving vasopressin therapy for treatment of diabetes insipidus. What will the nurse evaluate to assist in determining therapeutic response to this medication? 1. Urine specific gravity 2. Blood glucose 3. Vital signs 4. Oxygen saturation levels
Practice Question 36 A client has been receiving vasopressin therapy for treatment of diabetes insipidus. What will the nurse evaluate to assist in determining therapeutic response to this medication? 1. Urine specific gravity vasopressin alleviates polyuria by incr ADH secretion. Urine SG will incr as the urine is less dilute and will return to WNL 2. Blood glucose 3. Vital signs 4. Oxygen saturation levels
Gastrointestinal
Practice Question 37 A nurse is caring for a client following a cholecystectomy via an abdominal incision. What is the best position for this client? 1. Side-lying position, to prevent aspiration. 2. Semi-fowler’s position, to facilitate breathing. 3. Supine, to decrease strain on the incision line. 4. Prone, to reduce nausea.
A nurse is caring for a client following a cholecystectomy via an abdominal incision. What is the best position for this client? 1. Side-lying position, to prevent aspiration. 2. Semi-fowler’s position, to facilitate breathing. Note that the incision for this procedure is high on the abdomen and postop pain/discomfort can hinder respirations (lung expansion) 3. Supine, to decrease strain on the incision line. 4. Prone, to reduce nausea.
Practice Question 38 When teaching a client with hepatitis C who is receiving interferon and ribavirin therapy, the nurse encourages the client to eat 1. small frequent meals, high in carbohydrates. 2. small frequent meals, high in proteins. 3. 3 well balanced meals daily, high in carbohydrates. 4. 3 well balanced meals daily, but with minimal fluid intake.
When teaching a client with hepatitis C who is receiving interferon and ribavirin therapy, the nurse encourages the client to eat 1. small frequent meals, high in carbohydrates. Small frequ meals are recommended because of the drug’s s/e of nausea, vomiting, fatigue. 2. small frequent meals, high in proteins. 3. 3 well balanced meals daily, high in carbohydrates. 4. 3 well balanced meals daily, but with minimal fluid intake.
Practice Question 39 The nurse is caring for a client who has a bleeding duodenal ulcer. Which of the following assessment data would indicate gastric perforation? 1. Increasing abdominal distention and rigid abdomen 2. Decreasing hemoglobin and hematrocrit with bloody stools. 3. Diarrhea with increased bowel sounds and hypovolemia. 4. Decreasing blood pressure with tacycardia and disorientation.
The nurse is caring for a client who has a bleeding duodenal ulcer. Which of the following assessment data would indicate gastric perforation? 1. Increasing abdominal distention and rigid abdomen Perforation is characterized by incr distention and a “board-like” abdomen. 2. Decreasing hemoglobin and hematrocrit with bloody stools. May be seen with hemorrhage 3. Diarrhea with increased bowel sounds and hypovolemia. May be seen with hemorrhage 4. Decreasing blood pressure with tacycardia and disorientation. May be seen with hemorrhage
Practice Question 40 Which of the following interventions has the highest priority for a client following a esophagogastroduodenoscopy? 1. Assessing for the return of the gag reflex. 2. Giving warm gargles for a sore throat. 3. Monitoring complaints of heartburn. 4. Monitoring the temperature.
Which of the following interventions has the highest priority for a client following a esophagogastroduodenoscopy? 1. Assessing for the return of the gag reflex. ABC’s 2. Giving warm gargles for a sore throat. Psychosocial 3. Monitoring complaints of heartburn. 4. Monitoring the temperature. Important but would be a later complication
Practice Question 41 A nurse is preparing to assist the physician in performing a liver biopsy. The nurse would assist the client to which position for this test? 1. Right lateral side-lying 2. Left lateral side-lying 3. Prone with the hands crossed under the head 4. Supine with the right hand under the head.
Practice Question 41 A nurse is preparing to assist the physician in performing a liver biopsy. The nurse would assist the client to which position for this test? 1. Right lateral side-lying anatomical location of the liver makes this choice incorrect 2. Left lateral side-lying anatomical location of the liver makes this choice incorrect 3. Prone with the hands crossed under the head anatomical location of the liver makes this choice incorrect 4. Supine with the right hand under the head. Client is also instructed to remain as still as possible during the procedure.
Practice Question 42 The nurse is providing instructions to the client with a gastric ulcer regarding the administration of sucralfate (Carafate). The nurse instructs the client to 1. take the medication after meals & at bedtime with a snack. 2. take the medication with meals & at bedtime with a glass of milk. 3. to space the medication around the clock, taking it very 6 hours. 4. to take the medication 1 hour before meals and at bedtime.
The nurse is providing instructions to the client with a gastric ulcer regarding the administration of sucralfate (Carafate). The nurse instructs the client to 1. take the medication after meals & at bedtime with a snack. 2. take the medication with meals & at bedtime with a glass of milk. 3. to space the medication around the clock, taking it very 6 hours. 4. to take the medication 1 hour before meals and at bedtime. • sucralfate forms a protective coating over the gastric ulcer – food intake will stimulate gastric acid production and mechanical irritation • Take at bedtime to provide protective coating during night time hours.
Practice Question 43 A client who has returned from a percutaneous liver biopsy should be placed in what position? 1. Left side. 2. Right side. 3. Semi-Fowler’s 4. Supine
Practice Question 43 A client who has returned from a percutaneous liver biopsy should be placed in what position? 1. Left side. 2. Right side. 3. Semi-Fowler’s 4. Supine • Client placed on operative side (right side) • Pillow placed under the costal margin to compress the liver • Wt of client’s body will apply pressure to the liver and decr incidence of bleeding
Respiratory
Practice Question 44 A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse plans to 1. assess for a disconnection. 2. evaluate the cuff for a leak. 3. notify the respiratory therapist. 4. suction secretions from the client.
A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse plans to 1. assess for a disconnection. This would not cause the high pressure alarm to go off. 2. evaluate the cuff for a leak. This would not cause the high pressure alarm to go off. 3. notify the respiratory therapist. Delays necessary tx. 4. suction secretions from the client. High pressure alarm suggests an obstruction. Empty water from tubing…sx pt…check equipment…check pt (could be waking up and fighting the ventilator).
Practice Question 45 A client has a chest tube attached to a Pleur-evac drainage system. The nurse would ensure that 1. the connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site. 2. the amount of drainage into the chest tube is noted & recorded every 24 hours in the client’s record. 3. the suction control chamber has sterile water added every shift & that the system is kept below waist level. 4. the water seal chamber has continuous bubbling and that assessment for crepitus is done once a shift.
A client has a chest tube attached to a Pleur-evac drainage system. The nurse would ensure that 1. the connection between the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site. 2. the amount of drainage into the chest tube is noted & recorded every 24 hours in the client’s record. Drainage noted and recorded qhr in the 1 st 24 hrs then q 8 and prn. 3. the suction control chamber has sterile water added every shift & that the system is kept below waist level. Sterile water is added at initial set up and then only as needed (which is rare) 4. the water seal chamber has continuous bubbling and that assessment for crepitus is done once a shift. Continuous bubbling in the sx chamber. Bubbling in the water seal is a sign of an air leak. Assess for Crepitus q 8 hrs.
Practice Question 46 The nurse caring for a client with a closed chest drainage system notes that the tidaling in the water seal compartment has stopped. Based on this finding, the nurse would suspect that 1. the chest tubes are obstructed. 2. suction needs to be increased. 3. the system needs changing. 4. suction needs to be decreased.
Practice Question 46 The nurse caring for a client with a closed chest drainage system notes that the tidaling in the water seal compartment has stopped. Based on this finding, the nurse would suspect that 1. the chest tubes are obstructed. Or the pneumothorax is resolved…fluctuation continues until the thorax is resolved. 2. suction needs to be increased. Amt of sx is irrelevant…controlled via sx control chamber ; usu set at 20. 3. the system needs changing. Only change when drainage collection device is full or the device is damaged in some way. 4. suction needs to be decreased. Sx is often discontinued once drainage stops – waterseal is adequate for the resolution of the pneumothorax.
Practice Question 47 The client with tuberculosis asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when 1. 3 sputum cultures are negative. 2. 5 sputum cultures are negative. 3. a sputum culture & a chest x-ray film are negative. 4. a sputum culture & a Mantoux test are negative.
Practice Question the The client with tuberculosis asks 47 nurse when it is permissible to return to work. The nurse replies that the client may resume employment when 1. 3 sputum cultures are negative. 2. 5 sputum cultures are negative. 3. a sputum culture & a chest x-ray film are negative. 4. a sputum culture & a Mantoux test are negative. Mantoux will always be positive once it becomes positive. Do not repeat once the pt has a positive.
Practice Question 48 Which of the following should be performed prior to drawing arterial blood gases from the radial artery? 1. Allen’s test 2. Babinski’s reflex 3. Brudzinski’s sign. 4. Homans’ sigh
Practice Question 48 Which of the following should be performed prior to drawing arterial blood gases from the radial artery? 1. Allen’s test assesses for the adequ of ulnar circulation. 2. Babinski’s reflex performed on the sole of the foot – unrelated to a procedure performed on the radial artery. 3. Brudzinski’s sign. Assessment for nuchal rigidity by bending the head down toward the chest. 4. Homans’ sign sharp dorsiflexion of the feet – used to assess for thrombophlebitis.
Practice Question 49 A client with tuberculosis is to be started on rifampin (Rifadin). The nurse provides instructions to the client and tells the client 1. that yellow-colored skin is common. 2. to wear glasses instead of soft contact lens. 3. always to take the medication on an empty stomach. 4. that as soon as the cultures come back negative, the medication may be stopped.
A client with tuberculosis is to be started on rifampin (Rifadin). The nurse provides instructions to the client and tells the client 1. that yellow-colored skin is common. Indication of jaundice. Should report jaundice to MD. 2. to wear glasses instead of soft contact lens. Soft contacts may be damaged permanently by the orange discoloration that rifampin causes in body fluids. 3. always to take the medication on an empty stomach. Eliminate because of the word “always”may take with food if client is unable to tolerate on an empty stomach. 4. that as soon as the cultures come back negative, the medication may be stopped. Client will be on the meds a LONG time – as much as 12 months even if the cultures come back negative.
Practice Question 50 A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. The nurse develops a plan of care for the client and includes which of the following? 1. Providing the client with short, frequent walks. 2. Measuring the client’s pulse each shift. 3. Eliminating sources of caffeine from meal trays. 4. Limiting fluids given orally and IV.
A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. The nurse develops a plan of care for the client and includes which of the following? 1. Providing the client with short, frequent walks. Exercise will not alleviate tachycardia. 2. Measuring the client’s pulse each shift. Will not alleviate s/s and HR should be measured more freq. than qshift. 3. Eliminating sources of caffeine from meal trays. Cause exacerbation of the s/s. Caffeine is a stimulate. 4. Limiting fluids given orally and IV. Exercise will not alleviate tachycardia.
Practice Question 51 A client is experiencing an acute asthmatic attack. Which nursing action would improve the respiratory status of the client? 1. Help the client to attain a slow, prolonged expiration. 2. Have client forcefully exhale. 3. Provide rest by leaving client alone and in supine position. 4. Assist the client to breathe into a paper bag.
A client is experiencing an acute asthmatic attack. Which nursing action would improve the respiratory status of the client? 1. Help the client to attain a slow, prolonged expiration. This allows the client to exhale a greater volume and facilitates incr oxygenation. 2. Have client forcefully exhale. Used to measure peak airflow. 3. Provide rest by leaving client alone and in supine position. Client should be sitting or in high. Fowler’s position. Do not leave alone. 4. Assist the client to breathe into a paper bag. This will incr PCO 2 and not improve the pt’s overall condition.
Practice Question 52 A client with a pneumothorax has a chest tube inserted & connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe? 1. Continuous bubbling in the water-seal chamber. 2. Slight fluctuation of the water in the water-seal chamber. 3. Increased bloody drainage in the collection chamber. 4. Constant bubbling in the collection chamber.
A client with a pneumothorax has a chest tube inserted & connected to gravity drainage. When assessing the drainage system for proper function, what will the nurse expect to observe? 1. Continuous bubbling in the water-seal chamber. In the sx control chamber OK – in water seal suggests an air leak. 2. Slight fluctuation of the water in the water-seal chamber. Should fluctuate with breathing. 3. Increased bloody drainage in the collection chamber. Incr bloody drainage is never normal. 4. Constant bubbling in the collection chamber. Bubbling in the sx control chamber OK – collection chamber should not have bubbling.
B C A
Practice Question 53 The nurse would anticipate which nursing observation in the client with symptoms of early laryngotracheobronchitis? 1. Elevated temperature & prostration. 2. Flushed face & labored expirations. 3. Kussmaul respirations & bradycardia. 4. Tachypnea & inspiratory stridor.
Practice Question 53 The nurse would anticipate which nursing observation in the client with symptoms of early laryngotracheobronchitis? 1. Elevated temperature & prostration. Temperature not charactoristic 2. Flushed face & labored expirations. Could occur – but are not charactoristic – esp. early. 3. Kussmaul respirations & bradycardia. Deep rapid resp but are not noisy 4. Tachypnea & inspiratory stridor. Rapid, noisy resp. Occurs as air is drawn through a narrowed airway.
Practice Question 54 What are the nursing precautions during a tubing change of a central venous pressure (CVP) line? 1. Flush catheter with 3 ml of NS & then heparin before disconnecting the line. 2. Position client on right side & then have him take a deep breath. 3. Elevate HOB & disconnect tubing from fluid container before disconnecting from client. 4. Position client flat & have him take a deep breath & hold it while the line is disconnected & a new one connected.
Practice Question 54 What are the nursing precautions during a tubing change of a central venous pressure (CVP) line? 1. Flush catheter with 3 ml of NS & then heparin before disconnecting the line. Not necessarily. 2. Position client on right side & then have him take a deep breath. Position flat. 3. Elevate HOB & disconnect tubing from fluid container before disconnecting from client. Position flat. 4. Position client flat & have him take a deep breath & hold it while the line is disconnected & a new one connected. Increases intrathoracic pressure and so decr possibility that the client will experience an air embolus during the tubing change.
Practice Question 55 A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered? 1. Antihistamine 2. Bronchodilator. 3. Decongestant. 4. Expectorant.
Practice Question 55 A client has thick pulmonary secretions. The nurse would anticipate which classification of medication to be ordered? 1. Antihistamine block the release of histamine – used to tx mild allergic disorders. 2. Bronchodilator. Indicated when airways are inflamed and narrowed. 3. Decongestant. Produce vasoconstriction of dilated arterioles – leads to reduction in congestions. 4. Expectorant. Stimulate secr and reduce the viscosity of the mucus.
Practice Question 56 The nurse is monitoring a client who is receiving IV theophylline (aminophylline) for control of an acute episode of his chronic respiratory condition. What nursing observations would cause the nurse the most concern? 1. Blurred vision, halos around lights and diplopia. 2. Hypo. Kalemia, diarrhea, and bradycardia. 3. Restlessness, tachycardia, nausea, and vomiting. 4. Tachycardia, pulse oximetry of 90%, irregular respirations.
The nurse is monitoring a client who is receiving IV theophylline (aminophylline) for control of an acute episode of his chronic respiratory condition. What nursing observations would cause the nurse the most concern? 1. Blurred vision, halos around lights and diplopia. Does not relate to theophylline use. 2. Hypokalemia, diarrhea, and bradycardia. Does not relate to theophylline use. 3. Restlessness, tachycardia, nausea, and vomiting. Indicates toxic levels of theophylline. Lab work must be done to monitor theophylline levels. Normal range is 10 -20 mcg/ml. 4. Tachycardia, pulse oximetry of 90%, irregular respirations. Does not relate to theophylline use.
Practice Question 57 A nurse has an order to remove the NG tube from a first postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client? 1. Abdomen is slightly distended. 2. Bowel sounds are absent. 3. NG tube drainage is Hematest negative. 4. The client is drowsy.
A nurse has an order to remove the NG tube from a first postoperative day surgery client. The nurse would question the order if which of the following was noted on assessment of the client? 1. Abdomen is slightly distended. Cause for concern – but if active BS the distention should be resolved soon. 2. Bowel sounds are absent. GI system will continue to produce secretions even if pt is NPO – if no BS present they will remain in abdomen and present as an aspiration risk. 3. NG tube drainage is Hematest negative. This indicates a normal finding. 4. The client is drowsy. Drowsiness is not an indication for an NG tube
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