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The nurse is preparing to suction the client with a tracheotomy. There is no label to indicate the date or time of initial use.

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The nurse is aware that the most likely cause for the deduction of one point is:. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A client hospitalized with MRSA is placed on contact precautions.

Which statement is true regarding precautions for infections spread by contact? A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain? I will get you some pain medication. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:. The physician has ordered a minimal-bacteria diet for a client with neutropenia.

The client should be taught to avoid eating:. A client is discharged home with a prescription for Coumadin sodium warfarin. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:. A client has an order for streptokinase.

Before administering the medication, the nurse should assess the client for:. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was mL. The infant is admitted to the unit with tetralogy of Fallot.

The nurse would anticipate an order for which medication? The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence. Click to view larger image. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:.

The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:. The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse? The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:. A client with clotting disorder has an order to continue Lovenox enoxaparin injections after discharge. The nurse should teach the client that Lovenox injections should:.

The nurse has a preop order to administer Valium diazepam 10mg and Phenergan promethazine 25mg. The correct method of administering these medications is to:. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:.

The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:. See All Related Store Items. This chapter is from the book. Related Resources Store Articles Blogs. Taking hourly blood pressures with mechanical cuff. Encouraging fluid intake of at least mL per hour. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Roast beef, gelatin salad, green beans, and peach pie. Chicken salad sandwich, coleslaw, French fries, ice cream. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie. Pork chop, creamed potatoes, corn, and coconut cake. Chaperoning the local boys club on a snow-skiing trip. The body part that would most likely display jaundice in the dark-skinned individual is the: The client recently lost his job as a postal worker.

Oral mucous membrane, altered related to chemotherapy. Interrupted family processes related to life-threatening illness of a family member. It will be most important to teach the client and family about: Place the client in Trendelenburg position for postural drainage. Encourage coughing and deep breathing every two hours. Encourage the Valsalva maneuver for bowel movements.

The priority intervention for this client is: The most important measurement in the immediate post-operative period for the nurse to take is: Impaired physical mobility related to decreased endurance. During administration, the nurse should: The client should be instructed to: In assessing the client for edema, the nurse should check the: The nurse should place the zero of the manometer at the: The best method of evaluating the amount of peripheral edema is: The nurse should explain that: Overnight stays by family members is against hospital policy.

There is no need for him to stay because staffing is adequate. His wife will rest much better knowing that he is at home. Visitation is limited to 30 minutes when the implant is in place. Roast beef sandwich, potato chips, pickle spear, iced tea.

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The nurse should explain that a sponge bath is recommended for the first two weeks of life because: New parents need time to learn how to hold the baby. The chance of chilling the baby outweighs the benefits of bathing. The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic agents.

Create a synergistic effect that shortens treatment time. In addition to the DPT and polio vaccines, the baby should receive: The nurse should administer the medication: Call security for assistance and prepare to sedate the client. Tell the client to calm down and ask him if he would like to play cards. Tell the client that if he continues his behavior he will be punished. The next action the nurse should take is to: The nurse is aware that the client is exhibiting: The nurse is aware that the client is experiencing what is known as: Would you like something else?

A client with a diagnosis of HPV is at risk for which of the following? The nurse is aware that the most likely source of the lesion is: The best diagnostic test for treponema pallidum is: Stadol 1mg IV push every 4 hours as needed prn for pain. The infant is at low risk for congenital anomalies. The infant is at high risk for intrauterine growth retardation. The infant is at high risk for respiratory distress syndrome. An expected side effect of magnesium sulfate is: If the client experiences hypotension, the nurse would: The nurse is aware that uremic frost is often seen in clients with: Place the fruit next to the bed for easy access by the client.

Increase the frequency of neurological assessments. Which selection would provide the most calcium for the client who is four months pregnant? The nurse performs a vaginal exam every 30 minutes. The nurse places a padded tongue blade at the bedside. The best size cathlon for administration of a blood transfusion to a six-year-old is: The client can tell the nurse the normal blood glucose level.

The client asks for brochures on the subject of diabetes. The client demonstrates correct insulin injection technique. The client with AIDS should be taught to: Which action by the healthcare worker indicates a need for further teaching? The nursing assistant ambulates the elderly client using a gait belt. The nurse wears goggles while performing a venopuncture. The nurse washes his hands after changing a dressing. The nurse wears gloves to monitor the IV infusion rate. Prior to the ECT the nurse should: Treatment is not recommended for children less than 10 years of age. The client with a radium implant for cervical cancer.

The client with methicillin resistant-staphylococcus aureas MRSA. The doctor can be charged with: Which assignment should not be performed by the nursing assistant? Tell the mother to wash the face with soap and apply powder. Ask the mother if anyone else in the family has had a rash in the last six months. Which information should be reported to the state Board of Nursing? The facility fails to provide literature in both Spanish and English.

The narcotic count has been incorrect on the unit for the past three days. After talking to the nurse, the charge nurse should: Which client should be seen first? The year-old who had a gastrectomy three weeks ago and has a PEG tube. A client having auditory hallucinations and the client with ulcerative colitis. The client who is pregnant and the client with a broken arm.

A child who is cyanotic with severe dypsnea and a client with a frontal head injury. The client who arrives with a large puncture wound to the abdomen and the client with chest pain. The nurse should interpret this finding as: Draw up the Lantus insulin and then the regular insulin and administer them together.

Contact the doctor because these medications should not be given to the same client. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: Which action is contraindicated in the client with epiglottis? Recheck the O 2 saturation in 30 minutes. Which observation would the nurse expect to make after an amniotomy?

The client taking Glyburide Diabeta should be cautioned to: The first action the nurse should take is: Arterial ulcers are best described as ulcers that: The rationale for this implementation is: The contractions are intense enough for insertion of an internal monitor. Alteration in placental perfusion related to maternal position. Impaired physical mobility related to fetal-monitoring equipment. Potential fluid volume deficit related to decreased fluid intake. The most appropriate initial action would be to: A recurrent rate of 90—bpm at the end of the contractions.

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is: The bladder fills more rapidly because of the medication used for the epidural. Her level of consciousness is such that she is in a trancelike state. The sensation of the bladder filling is diminished or lost.

She is embarrassed to ask for the bedpan that frequently. The nurse explains that conception is most likely to occur when: The nurse is aware that the success of the rhythm method depends on the: Hamburger patty, green beans, French fries, and iced tea. Roast beef sandwich, potato chips, baked beans, and cola. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea. The client with hyperemesis gravidarum is at risk for developing: The most definitive sign of pregnancy is: The nurse will expect the neonate to be: An alternate method of birth control is needed when taking antibiotics.

If the client misses one or more pills, two pills should be taken per day for one week. Changes in the menstrual flow should be reported to the physician. Breastfeeding is contraindicated in the postpartum client with: The nurse should tell the client that labor has probably begun when: She experiences abdominal pain and frequent urination.

To provide postpartum prophylaxis, RhoGam should be administered: Nursing care of the newborn should include: Teaching the mother to provide tactile stimulation. Following the initiation of epidural anesthesia, the nurse should give priority to: The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to: Ask the client to cover her mouth when she coughs.

Which statement is true regarding balanced skeletal traction? Immediately following surgery, the nurse should give priority to assessing the: The urinary output has been ml during the last hour. The client has traveled out of the country in the last six months. In anticipation of complications of anesthesia and narcotic administration, the nurse should: Assisting the LPN with opening sterile packages and peroxide.

Telling the LPN that the registered nurse should perform pin care. Asking the LPN to clean the weights and pulleys with peroxide. The nurse is aware that the correct use of the walker is achieved if the: When assessing a laboring client, the nurse finds a prolapsed cord. The tube will allow for equalization of the lung expansion. Chest tubes relieve pain associated with a collapsed lung. Chest tubes assist with cardiac function by stabilizing lung expansion. The nurse is aware that successful breastfeeding is most dependent on the: When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for: Insulin requirements moderate as the pregnancy progresses.

A decreased need for insulin occurs during the second trimester. Elevations in human chorionic gonadotrophin decrease the need for insulin. Fetal development depends on adequate insulin regulation. The nurse should give priority to: The client will most likely be treated with: Stop the infusion of magnesium sulfate and contact the physician. Slow the infusion rate and turn the client on her left side. Administer calcium gluconate IV push and continue to monitor the blood pressure. Affected parents have a one in four chance of passing on the defective gene. Affected parents have unaffected children who are carriers.

The nurse should explain that the doctor has recommended the test: Fetal growth is arrested if thyroid medication is continued during pregnancy. At one minute, the nurse could expect to find: A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year? Shows the effect of contractions on the fetal heart rate. A full-term male has hypospadias.

Which statement describes hypospadias? The priority nursing diagnosis at this time is: Potential for injury related to precipitate delivery. Potential for fluid volume deficit related to NPO status. A Newbie's Guide to Apple Watch. How to write a great review. The review must be at least 50 characters long. The title should be at least 4 characters long. Your display name should be at least 2 characters long.

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Would you like us to take another look at this review? No, cancel Yes, report it Thanks! You've successfully reported this review. The first step in the nurse-client relationship is to establish trust in this therapeutic relationship. Without trust future collaboration, interventions and client outcomes cannot be accomplished to facilitate appropriate and safe behaviors. Lastly, sedating medications to prevent violence are also not the first things that are done. Amphetamines and hallucinogenic drugs like LSD are often associated with psychological dependence.

Substance abuse does not include prescribed medications, such as narcotic pain medications, that are being used for medical reasons; however, these same medications when used after there is no longer a medical need to use them is considered substance abuse. Contrary to popular opinion, addiction can occur with and without physical dependence.

Physical dependence occurs when the cessation of a drug causes adverse physical effects; these ill effects are typically greater and more intense when the cessation of the drug is rapid and abrupt. Some of the drugs that are most often associated with physical dependence include cocaine, opioid drugs, alcohol and benzodiazepines. As previously stated, physical dependence does not necessarily indicate addiction; addiction can be present with or without any physical dependency. This model describes self care needs and abilities as wholly compensatory, partly compensatory and supportive educative.

Lastly, biomedical models address pathology, impairments and the manifestations of impairments that can be cured or lead to death. Dissociation is the psychological ego defense mechanism occurs when the client detaches and dissociates with person or time to avoid the stress until they are ready to cope with it. Displacement allows the person to ventilate and act out on their anger in a less harmful and a more socially acceptable manner. A client uses the ego defense mechanism of sublimation when they transform and replace unacceptable urges and feelings into a socially acceptable urge or feeling.

A client is using reaction formation when the client acts and behaves in a manner that is completely the polar opposite of their true feelings. Caring consists of the following 10 nursing interventions that demonstrate genuine caring. Other goals are the freedom for guilt, spiritual distress and pain at the end of life; therefore, these diagnoses are not expected.

Additionally, the administration of an antiemetic to prevent vomiting is not indicated because there is no evidence in this question that the client is actually vomiting. After this statement, you should also educate the grandparents about the fact that group and family therapy is often indicated when the family unit is affected with stressors and dysfunction because family members may not fully understand the need for the entire family unit to participate when only one member of the family is adversely affected with a stressor and poor coping and that all family members are affected when only one member of the family unit is adversely affected.

This theory has four tasks that people go through after the loss of a loved one. Lastly, Lewin developed theories of change, leadership and conflict and NOT a theory related to grief after the loss of a loved one. Behavioral psychotherapy is particularly useful among clients who are adversely affected with phobias, substance related disorders, and other addictive disorders.

Some of the techniques that are used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling and complementary and alternative stress management techniques. This therapy is not conducted by registered nurses but, instead, by experienced psychotherapists. The client religion that is the most pertinent to the role of the admissions coordinator of hospital who assigns the rooms and beds of clients who will be admitted is the Islam religion which requires that the followers face Mecca for daily prayer, therefore, Islam clients should be placed in a room that faces the holy city of Mecca.

Although most religions impact on the care of the client, only Islam is pertinent to the admissions coordinator. Other religions practices and their impact on health care are shown below:. Delirium is characterized with a sudden and abrupt onset of episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity.

Visual hallucinations are a sign of delirium and delirium can result from a number of different causes including dehydration and anticholinergic medications. The signs and symptoms of sensory overload do not include visual hallucinations and a sudden and abrupt onset of episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity.

Instead, the signs and symptoms of sensory overload include anxiety, restlessness, sleep deprivation, fatigue, poor problem solving and decision making skills, poor performance, and muscular tension. There is no evidence in this question that the client has psychotic symptoms related to a previously undiagnosed psychosis; all the evidence substantiates the suspicion that the client is affected with delirium. The best way to evaluate the effectiveness of this educational series is to collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.

This technique entails evaluating the outcomes of the education in terms of changes in the client and it also includes formative evaluation during the series and summative evaluation at the end of the series. Collecting baseline blood pressure readings prior to the beginning of this educational series and then collecting and comparing blood pressure data after the series is completed gives us only summative evaluation; it does not provide you with formative evaluation.

Tai Chi is a type of a mind body exercise that deeply focuses on breathing, movement and meditation. Yoga is similar to tai chi in that yoga also employs a combination of breathing, movement and meditation. Feng shui is an eastern method of decorating using colors, items and the placement of objects in the environment to promote a harmonious relationship of man and its environment; and lastly Jiu Jitsu is a martial art.

You should teach the wife about this progressive disease and the need to promote as much independence as possible. Moving closer to the children may not be appropriate advice particularly if the children are unable or unwilling to care for their father. Lastly, you should advise the couple to continue their social activities and to only avoid those situations where the necessary compassion and understanding about the client and his condition are absent.

A therapeutic milieu eliminates as many stressors from the environment as possible. Some of the elements of a therapeutic milieu environment include consistency, client rules, limitations and boundaries, and client expectations, including contracts, relating to appropriate behavior.

The basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination is a button hook that would be used for the dressing activity of daily living. An aphasia aid and a word board are assistive devices to facilitate communication when the client is affected with a communication deficit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor fine motor coordination.

You should teach the client about the proper length of a cane. You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. Return-flow enemas, similar to a carminative enema, are used to relieve flatus and stimulate peristalsis which is frequently a problem after a client has received anesthesia.

Cleansing enemas are used to relieve constipation; and a retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate. Finally, the data in this question does not indicate that the client is constipated and in need of a laxative. The commonality that is shared in terms of both restraints and urinary catheters is that both are the last, not the first, treatment of choice.

Both indwelling urinary catheters and restraints pose risks and complication; therefore, both of these interventions must be prevented with the use of preventive measures. Indwelling urinary catheters are invasive but restraints are not invasive; indwelling urinary catheters can lead to infection but restraints do not. Lastly, neither are sentinel.

Some of the complications associated with a colostomy include a prolapsed stoma, infection, dehiscence, an ischemic ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and parastomal hernias.

A vitamin B12 deficiency, nocturnal enuresis and urinary stone formations are complications associated with urinary diversion and not fecal ostomy diversions. Urinary stasis and hypercalcemia, both hazards of immobility, can be prevented when the client will consume 2, mL of oral fluids per day. Lastly, calcium loss from the bones can be prevented by weight bearing activity, and not turning and positioning in bed. You would document the size of this wound as 24 cm. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound.

Secondary intention healing is the most likely type of wound healing for this client because of the risks associated with the deep infection associated with the ruptured appendix and the peritonitis. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own.

The resulting scar is more obvious than those scars that result from primary intention healing. Primary intention healing is facilitated with wounds without infection.

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The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some traumatic wounds are healed with tertiary intention.

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Primary, secondary and tertiary prevention strategies are prevention, interventions and restorative or rehabilitation care and not methods of wound healing. The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. RYB stands for the colors of red, yellow and black. The rules of treatment for these three colors are:. The severity of the pain, which can include a quantitative, numerical pain score from 1 to 10, for example, is the S of the PQRST method of pain assessment.

Anthropometric data, biochemical data, clinical data and dietary data are the A, B, C and Ds of a complete and comprehensive nutritional assessment. Aspiration can be prevented by maintaining the client in at least a 30 degree angle; a 90 degree angle is not only not necessary, this angle places a client at greater risk for the development of a pressure ulcer. Diarrhea, rather than constipation is a complication of tube feedings; and urinary pH changes are not a commonly occurring complication of tube feedings.

The age group that is accurately paired with the normal and recommended hours of sleep each day is the toddler should sleep about 11 to 14 hours per day. The neonate should sleep 14 to 17 hours per day; the preschool child should sleep 10 to 13 hours per day; and the school age child should sleep 9 to 11 hours per day. The next thing that you would do is assess the client to determine their physical status and to provide necessary emergency measures, including CPR, if it is indicated. Later, you would notify the doctor about this adverse reaction. The best way to determine whether or not a medication is compatible for a particular intravenous fluid is to refer to a compatibility chart.

Although, at times, incompatibility can be evidenced with changes such as those related to color changes and the formation of a cloudy solution or obvious precipitate, at other times incompatibility may not be noticeable. For this reason, nurses must refer to a compatibility or incompatibility chart before they mix medications or medications and solutions. Lastly, there is no need to call the doctor for compatibilities when you have, and should use, a compatibility chart. The complete and current list of medications is then reviewed by the nurse and possible interactions are identified and addressed with the client.

Although this medication reconciliation process can also save costs by eliminating unnecessary medications, particularly when the client is taking multiple medications polypharmacy , this is not a primary purpose. Lastly, medications that the client is allergic to should never be given, therefore, these medications should not appear during the medication reconciliation process; they should never have been given to or taken by the client.

Drugs classified as categories C, D and X are contraindicated for women who are pregnant because of the risks associated with these categories in terms of the developing fetus when these medications cross the placental barrier. The nurse must be knowledgeable about the fact that this client has A agglutinins and they lack the Rh factor. People also have a rhesus, or Rh, factor antigen or the lack of it. Clients with an Rh positive blood, which is the vast majority of people, have Rh positive blood and people without the Rh factor antigen have Rh negative blood.

Hemolysis can be prevented by typing and cross matching the blood and checking for ABO compatibility prior to administration. Febrile reactions are the most commonly occurring reaction to blood and blood products administration. Although a febrile reaction can occur with all blood transfusions, it is most frequently associated with packed red blood cells and this reaction is not accompanied with hemolysis nor is it associated with its occurrence. You will need the help of another nurse prior to the administration of these packed red blood cells. You have to determine how many tablets the patient will take if the doctor has ordered mg a day and the tablets are manufactured as mg per tablet.

You will criss cross multiply the known numbers and then divide this product by the remaining number to solve for X, as below. You have to determine how many mLs the patient will take if the doctor has ordered 10 mg twice a day and there are 12 mg in each mL. You have to determine how many mLs the patient will take if the doctor has ordered 6, units of heparin subcutaneously and there are 4, units in one mL. This calculation is done as follows:.

The next step is done using this rule that reflects the fact that there are 60 minutes per hour in order to determine the number of mLs per minute. With this type of calculation, the amount of normal saline that will be added to a powder in a vial to reconstitute the medication is important, instead, it is the amount of medication that results after the addition of the normal saline.

For example, this reconstituted medication yields it is the yield of 12 mg in an mL that is relevant. It is this that will be used in the calculation. When the doctor has ordered mLs of intravenous fluid every 8 hours, you would calculate the number of mLs per hour, as below.

Because you had mLs at 8 am, you should be prepared to hand another intravenous bag because this mLs should all be infused at 12 noon. You would administer this Benadryl because sleep inducement is an accepted off label use of this medication. The administration of an intramuscular injection to a neonate should be given in the vastus lateralis, rectus femoris and ventrogluteal muscle sites and not the deltoid or the gluteus maximus muscles because these muscles have not yet developed.

Ferrous sulfate IM is given using the Z Track technique to avoid the leakage and dark staining of the injection site with this medication. Ferrous sulfate is not administered with a subcutaneous injection or using the sublingual route. Lastly, the PQRST method is used to assess pain and not used as a guideline for medication administration. The steps for mixing NPH, the long acting insulin, with regular insulin, the short acting insulin in the correct sequential order are:.

You would stop the nurse from administering the injection when you observe that the nurse has palpated the gluteus maximum muscle to determine the correct site. Intramuscular injection sites are determined by using boney landmarks and not by palpating the muscle.

You would not allow the nurse to administer the injection and you would not ask the nurse to use the vastus lateralis muscle instead because nothing indicates the need to do so. All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances that are wasted for any reason, either in its entirety or only partially, must be witnessed or documented by the wasting nurse and another nurse.

Both nurses document this wasting. It should not be necessary for you to ask another nurse to verify this calculation; the nurse is accountable and responsible for accurate dosage calculations. Compile a list of current medications and other preparations 1. Compile a list of newly prescribed medications 4. Compare the two lists and make note of any discrepancies and inconsistencies 5. Employ critical thinking and professional judgments during the comparisons of the two lists 6. Communicate and document the new list of medications to the appropriate healthcare providers.

The client with cancer who is receiving bendamustine is at greatest risk for extravasation. Extravasation occurs when vesicant and other vein irritating drugs infiltrate into the tissue. In severe cases, extravasation can lead to necrosis and the loss of an affected limb. Bendamustine is a vesicant chemotherapy drug. Extravasation is not associated with the intravenous administration of Ringers lactate or potassium supplementation intravenously because this solution and medication are not vesicants. These intravenous preparations can lead to infiltration but not extravasation.

Lastly, the client who is receiving total parenteral nutrition is at risk for other complications such as infection, but not extravasation. In addition to other interventions, intravenous fluid contents including blood are aspirated from the IV cannula. Other interventions include immediate cessation of the infusion, elevating the limb, applying warm compresses initially to rid the area of any remaining drug that is in the tissues which is then followed by cool compresses to reduce any swelling, and the administration of an ordered substance specific medication such as dexrazoxane.

One of the interventions for infection include the elevation, not lowering, of the affected limb; infiltration is treated with the application of warm, not cold, compresses and one of the interventions for hematoma is the application of pressure and heat and not the administration of dexrazonxane. Observational behavioral pain assessment scales for the pediatric population are used among children less than three years of age. The side effects and adverse reactions to this classification of drugs include constipation, sedation, nausea, dizziness, pruritus, and sedation, respiratory depression and arrest, hepatic damage, an anaphylactic reaction, circulatory collapse and cardiac arrest.

Opioid antagonists also referred to as opioid receptor antagonists, such as naloxone and naltrexone, can have side effects such as hepatic damage, joint pain, insomnia, vomiting, anxiety, headaches and nervousness. The client may be experiencing an embolus, which is a complication of total parenteral nutrition. Some of the signs and symptoms of an embolus are chest pain, dyspnea, shortness of breath, coughing, and respiratory distress. Emboli, secondary to total parenteral nutrition occur when air is permitted to enter this closed system during tubing changes and when a new bottle or bag of hyperalimentation is hung.

An inadvertent pneumothorax can occur and become symptomatic during the insertion of the TPN catheter and not four days later. The client should perform the Valsalva maneuver when the nurse changes the TPN tubing to prevent an embolus which can occur when the tubing is opened to the air while it is being changed. Lastly, clients are at risk for infection secondary to TPN because these solutions are high in dextrose and because TPN is an invasive sterile procedure; and clients are at high risk for hyperglycemia when they are getting TPN because these solutions are high in dextrose and not because the client is already a diabetic client.

All of these vital signs are normal for the toddler who is 2 years old. The normal vital signs for the toddler are:. The respiratory rate is a little too fast for this 5 year old preschool client. The normal respiratory rate for this client should be from 22 to 30 per minute. The normal pulse rate and blood pressure for the preschool child are from 80 to beats per minute and a diastolic from 50 to 78 mm Hg and a systolic from 82 to mm Hg.

You would report the pulmonary artery wedge pressure of 22 mm Hg because the normal pulmonary artery wedge pressure is from 4 to 12 mm Hg. You would instruct your female client to use a new antiseptic wipe for each wipe from the inner to the outer labia. A principle of asepsis is the cleansing of areas from the cleanest to the dirtiest and NOT the reverse; therefore, the inner labia are cleansed before the outer labia.

The female perineal area is prepped with straight strokes and wipes; and the male wipes with a circular pattern around the urinary meatus. Pricking the pad of the finger using the lancet is NOT a step in the procedure for obtaining a blood glucose sample for testing. Instead, the side of the finger is pricked with the lancet. The normal partial pressure of oxygen PaO2 is from 75 to mm Hg. You would report a total cholesterol level of 6. A 64 year old male client who has hypotension is at greatest risk for impaired vascular perfusion. Alcohol abuse, cigarette smoking and exposures to radon place people at risk for cancer, rather than impaired perfusion.

The client who is at greatest risk for the development of cancer is the 76 year old female client who has a history of alcohol abuse. Data indicates that alcohol abuse can lead to cancer of the liver and other cancers. Diabetes, a history of impaired oxygen transport and hypotension are risk factors associated with poor tissue perfusion, and not cancer.

The Norton Scale and the Braden Scale are standardized tools to screen clients for their risk of skin breakdown, pressure ulcers and an impairment of skin integrity. Pain levels among school age children are measured with other standardized pain tools for pediatric clients; and levels of muscular strength and mobility are measured also with other standardized tests and not the Norton Scale.

Impaired tissue perfusion is an intrinsic, or internal, risk factor that places the client at risk for pressure ulcers. Pressure, shearing and friction are extrinsic, or external, risk factors that places the client at risk for pressure impaired tissue perfusion. The first thing that you should do when you insert the suction catheter and you reach a point of resistance is to deflate the cuff when it is inflated and the second thing that you should do is to remove the inner cannula and suction out the mucous plug.

You would not call the doctor because there is an airway obstruction; you should correct this problem with the measures above. You would teach the client about the fact that they may have a headache after the ECT. Other components of the teaching about the aftermath of the procedure that the client should know about include the fact that the client may have muscle soreness, not muscle flaccidity, confusion, amnesia and hypertension.

Strangulation, skin breakdown and skin pallor can also occur when a restraint is too tight, however, these restraint complications are respiratory, integumentary system and circulatory system complications rather than neurological complications. The appearance of petechiae is a sign of thrombocytopenia which is a low platelet count.

Other signs and symptoms include purpura, easy bruising, epistaxis, and spontaneous hemorrhage and bleeding. The complication that you should be aware of during the immediate post-operative period of time after a thoracentesis is a pneumothorax. The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness of breath and pain. Infection would not be evident during the immediate post-operative period; and, aspiration is not a complication of a thoracentesis.

The strength, volume and fullness of the peripheral pulses are categorized and documented as follows:. The tool or scale that you would use for a focused neurological assessment of your client is the Rancho Los Amigos Scale. Levels of consciousness, which is part of a complete focused neurological assessment, can be determined and measured by using the standardized Glasgow Coma Scale for adults and children or the Rancho Los Amigos Scale.

The McGill Pain Assessment is used to assess pain levels; the Lazarus Cognitive Appraisal Scale is used to assess levels of stress and coping; and the Hamilton Rating Scale is used to measure and assess depression. A lack of zinc, copper, iron and vitamins C and A are risks associated with impaired and delayed wound healing.

Stage 2 of general anesthesia, often referred to as the Excitement Stage, is characterized with uncontrollable muscular activity, irregular respirations, an irregular cardiac rhythm, and, at times, vomiting. This stage does not indicate the need for more general anesthesia. Anesthesia awareness, which is a rare complication of general anesthesia, is the lack of amnesia during surgery when the client remembers events during surgery and, at times, they remember the pain. Medication reconciliation prevents medication errors and other complications associated with medications and not a way to reduce surgical risks.

Surgical marking, time outs that are done after surgical site marking is done, and a neutral zone for sharps do reduce surgical risks such as wrong site surgery, wrong patient surgeries and sharps injuries. Brachytherapy is internally placed radioactive material to treat clients who are affected with tumor and cancer of the prostate, lungs, esophagus, cervix, endometrium, rectum, breast, head and neck. Special radiation precautions are initiated when a client is receiving brachytherapy in order to protect visitors and health care staff from the harmful effects of the radiation.

Some of the other special internal radiation precautions include:. Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue.

Alopecia, and oral dryness which is also referred to as xerostomia, are side effects and complications to radiation, but not adverse effects. Other side effects, complications and adverse effects associated with therapeutic radiation therapy are:. You would monitor the color of the stools for the client who is receiving phototherapy.

Phototherapy is used to treat psoriasis, but it is most commonly employed for the treatment of neonatal hyperbilirubinemia and jaundice which can occur among both full term and pre term infants. Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the number of beats per minute. Sinus bradycardia has a cardiac rate less than 60 beats per minute, the atrial and the ventricular rhythms are regular, the P wave occurs prior to each and every QRS complex, the P waves are uniform in shape, the length of the PR interval is form 0.

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Atrial flutter, which is a relatively frequently occurring tachyarrhymia; this cardiac rhythm is characterized with an rapid atrial rate of to beats per minute, a variable ventricular rate, a regular atrial rhythm, a possibly irregular ventricular rhythm, the P waves are not normal, the flutter wave has a saw tooth look f waves , the PR interval is not measurable, QRS complexes are uniform and the length of these QRS complexes are from 0. Supraventricular tachycardia, simply defined is all tachyarrhythmias with a heart rate of more than beats per minute.

The two types of ventricular fibrillation that can be seen on an ECG strip are fine ventricular fibrillation and coarse ventricular fibrillation; ventricular fibrillation occurs when there are multiple electrical impulses from several ventricular site. You would instill mLs of irrigating solution after each suctioning of the nasogastric tube. The typical amount of irrigating solution is from 20 mLs to mLs.

You should explain that superior vena cava syndrome is pressure on the vena cava which is a major vein, not an artery, in the body that carries blood from the systemic circulation to the right atrium of the heart. This is a life threatening medical emergency.

You would most likely suspect that this client is affected with a dissected thoracic aneurysm. The signs and symptoms of hypovolemic shock vary according to the stage of the shock; some of the signs and symptoms include hypotension, tachycardia, a lack of tissue perfusion, hyperventilation, decreased cardiac output, decreased urinary output, oliguria, anuria, metabolic acidosis, increased blood viscosity, and multisystem failure.

The signs and symptoms of septic shock include the classical signs of infection in addition to hypotension, confusion, metabolic acidosis, respiratory alkalosis, abnormal breath sounds like crackles and rales, a widened pulse pressure, and decreased cardiac output. Intussusception occurs when a part of the intestine slides into another part of the intestine.

This medical emergency can lead to poor perfusion to the intestine. The signs and symptoms of intussusception include knee to chest posturing, abdominal pain, bloody stool, fever, constipation, vomiting and diarrhea. A ruptured appendix occurs when an infected appendix ruptures; a stoma retraction occurs when an ileostomy stoma retracts below the abdominal surface; and pneumonia occurs when the lungs become infiltrated.

You would not administer a thrombolytic medication; however, you would likely administer analgesic medications for the pain associated with the sickle cell crisis. The lithotomy position is used for procedures involving the pelvis, including gynecological examinations; and the Trendelenburg position is used when the client is in shock and with significant hypotension.

You would encourage the person to continue coughing because this person has a partial airway obstruction. You would perform the Heimlich maneuver when the person has a complete airway obstruction. CPR and ACLS may be necessary later, but not now as based on the fact that the person only has a partial airway obstruction. Lastly, the Valsalva maneuver is done when one exerts pressure against resistance. Unlike Neisseria gonorrhoeae, trichomoniasis and infections caused by E.

The type of immunity occurs when a person has an infectious, communicable disease like the measles is active natural immunity. Active immunity occurs as the result of our bodily response to the presence of an antigen, with the development of antibodies. Active immunity can be both natural and artificial. Natural active immunity occurs when the body produces antibodies after the client is infected with a pathogen; and artificial active immunity occurs when the body produces antibodies to an immunization vaccine such as those for pneumonia and a wide variety of childhood infectious diseases.

Adaptive immunity is the acquisition of antibodies or activated T cells in the body. + NCLEX-RN Questions (and Answers) eBook: Minute Help Guides: Kindle Store

Passive immunity occurs when an antibody is introduced into the body by either natural or artificial means. Passive natural immunity occurs when the fetus and neonate receive immunity as a natural process through the placenta; and passive artificial immunity occurs when the client receives an injection of immune globulin. The prodromal stage, or phase, of the infection process is characterized with general malaise, joint and muscular aches and pains, anorexia, and the presence of a headache.

The prodromal stage begins with the onset of symptoms and this stage is characterized with the replication and reproduction of the pathogen. The incubation stage is asymptomatic; the illness stage is the period of time that begins with continuation of the signs and symptoms and it continues until the symptoms are no longer as serious as they were before; and the convalescence stage is the period of recovery during which time the symptoms completely disappear.

Automated external defibrillators can be easily used by people with no healthcare experience. Automated external defibrillators are simple to use and there is no need to be able to recognize cardiac arrhythmias or interpret cardiac rhythm strips. Automated external defibrillations are intended to be used by the general public without any healthcare or nursing knowledge of experience; therefore, they are not restricted to only those BLS certified.