NCLEX- RN Practice Exam 9

EXPLANATION

 

✔Correct answers:

Notify the registered nurse. Nurse Lily should immediately notify the registered nurse (RN) as part of the rapid response to Baby Ryan’s acute cyanotic episode. The RN can assist in coordinating emergency care, contacting the physician, and providing additional support during this critical situation.

Prepare to administer morphine sulfate. Morphine sulfate can help reduce the hypercyanotic spell (also known as a "tet spell") by decreasing pulmonary vascular resistance, calming the infant, and reducing the workload on the heart. It is an important medication in managing acute cyanotic episodes in tetralogy of Fallot.

Prepare to administer intravenous fluids. Administering IV fluids can help increase circulating volume, which may improve cardiac output and oxygen delivery. This is especially important in a cyanotic episode where perfusion is compromised.

Prepare to administer 100% oxygen by face mask. Administering 100% oxygen can help increase the oxygen saturation in the blood, although it may not fully correct the hypoxemia due to the anatomical heart defects in tetralogy of Fallot. Oxygen is a crucial immediate intervention to stabilize the infant.

Think of the heart as a pump and the oxygen as the fuel. If the pump struggles and the fuel level drops suddenly, you need to quickly increase the fuel supply (oxygen) and reduce the pump's workload (morphine and IV fluids) to keep things running smoothly.

 

✘Incorrect answer options:

Call a code blue. While this is a serious situation, calling a code blue is typically reserved for cardiac or respiratory arrest. Baby Ryan is experiencing a cyanotic spell, which requires immediate intervention but not necessarily a full code response.

Place the infant in a prone position. The appropriate position for a cyanotic spell in an infant with tetralogy of Fallot is the knee-chest position. This position helps increase systemic vascular resistance, which can reduce the right-to-left shunt and improve oxygenation. Prone positioning is not beneficial in this context.

 

References

• Hockenberry, M. J., & Wilson, D. (2018). Wong's Nursing Care of Infants and Children. Elsevier.
• Nichols, D. G. (2016). Rogers' Textbook of Pediatric Intensive Care. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

A 10-year-old female client with a urinary tract infection. The 10-year-old female client with a urinary tract infection (UTI) should be advised against taking herbal medications. Children are more vulnerable to the effects of medications, including herbal remedies, due to differences in metabolism, body composition, and organ function compared to adults. The safety and efficacy of many herbal medications have not been established in pediatric populations. Additionally, UTIs require appropriate antibiotic treatment to prevent complications, and relying on herbal medications alone could delay necessary medical care.

Herbal medications can have potent pharmacological effects and potential interactions with conventional medications. Since children metabolize substances differently than adults, the risk of adverse reactions or ineffective treatment is higher. Ensuring that a UTI is treated effectively with antibiotics is crucial to avoid kidney infections or other serious complications.

Think of a child’s body as a small garden. Just as a gardener would be cautious about using strong fertilizers or pesticides in a small garden to avoid harming delicate plants, healthcare providers must be cautious with medications, including herbal ones, in children.

Nurse Adams should educate the client's family about the importance of adhering to prescribed antibiotic therapy and the potential risks associated with using herbal medications in children. Ensuring that the UTI is treated effectively with evidence-based medicine is essential.

• Educate the family about the importance of completing the prescribed antibiotic course to fully eradicate the infection.
• Discuss the potential risks and lack of evidence regarding the use of herbal medications in children.
• Advise on the importance of monitoring for signs of worsening infection or complications and seeking prompt medical attention if needed.
• Provide resources or referrals to a pediatrician or pharmacist for further information on safe medication use in children.

 

✘Incorrect answer options:

A 60-year-old male client with rhinitis. While it is important to consider interactions with other medications and conditions, this client is not inherently at higher risk from herbal medications due to rhinitis alone, assuming other factors are normal.

A 24-year-old male client with a lower back injury. This client might use herbal medications for pain relief, and while interactions and efficacy should be evaluated, the age and condition do not inherently contraindicate herbal use.

A 45-year-old female client with a history of migraine headaches. Herbal medications are sometimes used for migraine prevention or relief. While it is crucial to monitor for interactions and efficacy, this history alone does not inherently contraindicate herbal use, provided they are used under professional guidance.

 

References

• Gardiner, P., & Kemper, K. J. (2000). Herbal and dietary therapies in pediatric patients. Pediatrics, 106(1), 175-179.
• Wong, D. L., Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2015). Wong's Essentials of Pediatric Nursing. Elsevier.

EXPLANATION

 

✔Correct answer:

Postural blood pressure changes. Hyponatremia, or low sodium levels in the blood, often occurs alongside dehydration, especially in patients who may be experiencing fluid loss or inadequate intake. One of the signs of hyponatremia, particularly when it accompanies dehydration, is postural (orthostatic) blood pressure changes. This means that the patient may experience a significant drop in blood pressure when moving from a lying to a standing position, leading to dizziness or lightheadedness.

Hyponatremia affects the body's ability to regulate fluid balance and blood pressure. When sodium levels are low, water can move into cells, leading to cellular swelling. However, in the context of dehydration, overall fluid volume in the body is reduced, which can manifest as poor skin turgor and flat neck veins. The body's attempt to maintain blood pressure under these conditions can result in orthostatic hypotension.

Think of blood pressure like the water pressure in a garden hose. When there's less water (dehydration) and the pressure drops significantly when you open the nozzle (stand up), you experience a weak flow (dizziness and postural changes).

Nurse Carter should monitor Mr. Johnson’s blood pressure in different positions (lying, sitting, and standing) to assess for orthostatic changes and continue to observe for other symptoms of hyponatremia and dehydration.

• Measure and record blood pressure and pulse in supine, sitting, and standing positions to detect orthostatic hypotension.
• Monitor for other signs of hyponatremia, such as headache, nausea, confusion, and muscle cramps.
• Assess and maintain fluid balance by monitoring intake and output and considering the need for IV fluids if appropriate.
• Educate the patient about the symptoms of hyponatremia and dehydration and the importance of maintaining adequate fluid and electrolyte intake.
• Collaborate with the healthcare team to adjust treatment plans based on the patient's sodium levels and clinical status.

 

✘Incorrect answer options:

Intense thirst. Intense thirst is more commonly associated with hypernatremia (high sodium levels) rather than hyponatremia. Thirst is the body's way of signaling the need for more fluid to dilute high sodium levels.

Slow, bounding pulse. A slow, bounding pulse is not typically associated with hyponatremia. This pulse quality is more often seen in conditions of fluid overload or other cardiovascular issues, not in the context of dehydration and hyponatremia.

Dry mucous membranes. While dry mucous membranes are a sign of dehydration, they are not specific to hyponatremia. They indicate a general state of fluid deficit but do not specifically point to low sodium levels.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answers:

Monitor for signs of hemorrhage. After retinal detachment surgery, it is crucial to monitor for signs of hemorrhage. Post-operative hemorrhage can lead to complications, including increased intraocular pressure and vision loss. Signs to watch for include sudden vision changes, increased eye pain, and visible blood in the eye.

Administer prescribed eye medications. Administering prescribed eye medications is essential to prevent infection, reduce inflammation, and promote healing. These medications might include antibiotics, corticosteroids, and other anti-inflammatory agents.

Ensure the eye patch or shield remains in place. Keeping the eye patch or shield in place is vital to protect the eye from injury, reduce movement, and allow proper healing. It also helps prevent accidental rubbing or pressure on the operated eye.

Assist with activities of daily living. Assistance with activities of daily living (ADLs) is necessary to prevent strain on the eye and ensure safety during the recovery period. Activities like bending, lifting, and sudden head movements should be avoided to prevent increased intraocular pressure.

Educate the patient about symptoms of retinal detachment. Educating Mrs. Lewis about the symptoms of retinal detachment is crucial for early detection of any recurrence. Symptoms include sudden flashes of light, an increase in floaters, and a shadow or curtain over part of the visual field.

Think of the eye as a delicate piece of machinery that has just been repaired. Post-operative care involves ensuring no additional damage (monitor for hemorrhage), using the correct lubricants (eye medications), keeping it covered and protected (eye patch), avoiding unnecessary strain (assistance with ADLs), and knowing the warning signs of malfunction (symptoms of retinal detachment).

 

✘Incorrect answer option:

Encourage coughing and deep breathing. While coughing and deep breathing exercises are important after many types of surgery to prevent respiratory complications, they are not a priority after retinal detachment surgery. These activities could increase intraocular pressure, potentially disrupting the surgical repair.

 

References

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Breathing that is abnormally deep, regular, and increased in rate. Kussmaul's respirations are characterized by abnormally deep, regular, and increased rate of breathing. This type of respiration is a compensatory mechanism in response to metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body produces excessive ketones, leading to acidosis. The deep and rapid breathing helps to blow off carbon dioxide (CO2), a component of the body's acid load, to help correct the pH imbalance.

In diabetic ketoacidosis, the lack of insulin leads to the breakdown of fats for energy, resulting in the production of ketones, which are acidic. The body attempts to compensate for this metabolic acidosis by increasing the rate and depth of respiration to excrete more CO2, thereby reducing the acid load and partially correcting the acidosis.

Imagine a house filled with smoke (acid). Opening the windows wide and turning on fans (Kussmaul’s respirations) helps to quickly clear out the smoke, making the air cleaner (balancing pH).

Nurse Parker should continue to monitor Mr. Lewis closely for signs of worsening acidosis and other complications of DKA. Interventions may include administering insulin, fluids, and electrolytes as prescribed, and continually reassessing the patient’s respiratory status.

• Monitor arterial blood gases (ABGs) to assess the severity of acidosis and the effectiveness of respiratory compensation.
• Administer insulin therapy to reduce blood glucose and ketone levels.
• Provide IV fluids to correct dehydration, a common issue in DKA.
• Monitor electrolytes, particularly potassium, which can be significantly affected by both DKA and its treatment.
• Educate the patient and family about the signs and symptoms of DKA and the importance of regular blood glucose monitoring and insulin administration.

 

✘Incorrect answer options:

Breathing that stops for several seconds. This describes apnea, which is not characteristic of Kussmaul’s respirations and does not relate to the compensatory mechanism seen in DKA.

Breathing that is regular but unusually slow. This describes bradypnea, which is not typical of Kussmaul’s respirations and would not be an effective response to metabolic acidosis.

Breathing that is labored, with increased depth and rate. While this option is close, the term "labored" suggests difficulty, whereas Kussmaul’s respirations, though deep and rapid, are typically not described as labored. They are deep, regular, and increased in rate, indicating a deliberate effort to correct acidosis.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Metabolic alkalosis. Ms. Thompson, who has a nasogastric tube attached to low suction, is at risk of developing metabolic alkalosis. This condition occurs when there is an excessive loss of stomach acids, primarily hydrochloric acid, which can happen with prolonged nasogastric suctioning. The loss of these gastric acids leads to a decrease in hydrogen ions (H+), causing the body's pH to rise and resulting in alkalosis.

The stomach secretes hydrochloric acid to aid in digestion. When gastric contents are continuously suctioned, the body loses these acids. To compensate, the kidneys retain bicarbonate (HCO3-), further contributing to the alkalotic state. This disruption in the acid-base balance can result in symptoms such as confusion, muscle twitching, and even cardiac arrhythmias if severe.

Imagine the body's acid-base balance as a balanced scale. Removing too much acid is like taking weights off one side of the scale, causing it to tip and create an imbalance (alkalosis).

Nurse Wilson should monitor Ms. Thompson's electrolyte levels, particularly potassium and chloride, as these can be affected by metabolic alkalosis. Regular assessment of blood gas values, as well as watching for signs of alkalosis, is critical.

• Monitor arterial blood gases (ABGs) to detect changes in pH and bicarbonate levels.
• Assess for clinical signs of metabolic alkalosis, such as confusion, hand tremors, light-headedness, muscle twitching, and nausea.
• Check electrolyte levels, especially potassium and chloride, as imbalances can exacerbate the condition.
• Adjust the suction settings as appropriate and consider intermittent rather than continuous suction to minimize acid loss.
• Collaborate with the healthcare provider to possibly administer IV fluids or electrolyte replacements if necessary.

 

✘Incorrect answer options:

Metabolic acidosis. This condition occurs due to an accumulation of acids or loss of bicarbonate but is less likely with nasogastric suctioning, which primarily removes gastric acids.

Respiratory acidosis. This condition is caused by an accumulation of carbon dioxide due to hypoventilation and is not related to nasogastric suctioning.

Respiratory alkalosis. This condition results from excessive loss of carbon dioxide due to hyperventilation and is also unrelated to nasogastric suctioning.

 

References

• Gannon, R. H., & Kane, K. L. (2018). Fluids and Electrolytes with Clinical Applications. Cengage Learning.
• Metheny, N. A. (2017). Fluid and Electrolyte Balance: Nursing Considerations. Jones & Bartlett Learning.

EXPLANATION

 

✔Correct answer:

Gloves, a gown, and goggles. When performing colostomy care for a patient with MRSA on contact precautions, it is essential to use appropriate personal protective equipment (PPE) to prevent the transmission of the infection. This includes gloves, a gown, and goggles. Gloves and a gown protect the nurse from direct contact with the patient's bodily fluids and contaminated surfaces, while goggles protect the eyes from splashes and aerosols that may occur during colostomy care.

MRSA is a highly transmissible bacterium that can spread through direct contact with infected body fluids or contaminated surfaces. Proper use of PPE is critical in preventing the spread of MRSA to other patients and healthcare workers.

Think of PPE like armor. Just as armor protects a knight from various threats, gloves, a gown, and goggles protect healthcare workers from infectious agents.

Nurse Morgan should follow standard infection control protocols by donning the appropriate PPE before starting the colostomy care. This ensures both the nurse’s safety and the prevention of cross-contamination.

• Ensure proper hand hygiene before and after the procedure.
• Wear gloves to protect hands from direct contact with bodily fluids.
• Wear a gown to protect clothing and skin from contamination.
• Wear goggles to protect eyes from any potential splashes or aerosols.
• Follow proper disposal procedures for contaminated PPE after the procedure.

 

✘Incorrect answer options:

Gloves along with a gown. While gloves and a gown are essential, goggles are also necessary to protect against potential splashes and aerosols, making this option incomplete.

Gloves along with goggles. Gloves and goggles provide protection for the hands and eyes, but a gown is also necessary to protect clothing and skin from contamination, making this option incomplete.

Gloves, a gown, and shoe covers. While gloves and a gown are necessary, shoe covers are not typically required for colostomy care. Goggles are more crucial for protecting against splashes and aerosols.

 

References

• Centers for Disease Control and Prevention. (2020). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Address hypocalcemic tetany. Calcium gluconate is prescribed for Ms. Taylor to address hypocalcemic tetany, a potential complication following thyroidectomy. During a thyroidectomy, the parathyroid glands, which regulate calcium levels, may be inadvertently damaged or removed. This can lead to hypocalcemia (low calcium levels in the blood), which may cause tetany—a condition characterized by muscle cramps, spasms, and twitching due to increased neuromuscular excitability.

The parathyroid glands produce parathyroid hormone (PTH), which helps regulate calcium levels in the blood. If these glands are damaged or removed, PTH production drops, leading to decreased calcium levels. Administering calcium gluconate helps quickly restore calcium levels, thus preventing or treating symptoms of hypocalcemic tetany.

Imagine the parathyroid glands as a thermostat controlling the heating system (calcium levels) in a house. If the thermostat is damaged, the temperature (calcium levels) drops, causing discomfort. Administering calcium gluconate is like adding extra heat to quickly restore a comfortable temperature.

Nurse Rodriguez should monitor Ms. Taylor for signs of hypocalcemia, such as tingling around the mouth or in the fingers and toes, muscle spasms, and Chvostek's or Trousseau's signs. Prompt administration of calcium gluconate is crucial in managing these symptoms.

• Monitor the patient's calcium levels regularly to ensure they remain within the normal range.
• Assess for signs and symptoms of hypocalcemia, including muscle cramps, spasms, or twitching.
• Administer calcium gluconate as prescribed and monitor the patient for any adverse reactions.
• Educate the patient about the importance of reporting symptoms of hypocalcemia immediately.
• Collaborate with the healthcare team to adjust treatment based on the patient’s calcium levels and symptoms.

 

✘Incorrect answer options:

Manage thyroid storm. Thyroid storm is a severe hyperthyroid condition that is not directly related to calcium levels. Treatment typically involves medications to reduce thyroid hormone levels and manage symptoms, not calcium gluconate.

Prevent cardiac irritability. While calcium plays a role in cardiac function, calcium gluconate is specifically prescribed here to address hypocalcemia and prevent tetany rather than cardiac irritability.

Stimulate parathyroid hormone release. Calcium gluconate does not stimulate the release of parathyroid hormone. It directly supplements calcium levels in the blood to manage hypocalcemia.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answers:

In a semi-Fowler’s position. Placing Mr. Johnson in a semi-Fowler’s position (head of bed elevated 30-45 degrees) helps reduce intracranial pressure (ICP) and promotes venous drainage from the brain. This position is beneficial post-craniotomy to facilitate recovery and prevent complications related to increased ICP.

With the head in a midline position. Keeping the head in a midline position helps ensure proper venous drainage from the brain, reducing the risk of increased ICP. Avoiding lateral or extreme head positions minimizes compression of the jugular veins and enhances cerebral circulation.

Think of the brain like a delicate garden. To ensure the garden thrives, you need to keep the soil (the brain) well-drained by keeping it slightly elevated and level (head in a semi-Fowler's position and midline). Avoiding any sharp bends or pressure on the garden bed (no neck flexion or extreme hip flexion) helps the water (blood) flow freely without flooding or drying out the plants (brain cells).

Nurse Karen should closely monitor Mr. Johnson’s neurological status and ICP, ensuring proper positioning to enhance recovery and prevent complications.

• Regularly assess neurological status, including level of consciousness, motor function, and pupillary responses.
• Maintain the head of the bed elevated at 30-45 degrees unless otherwise contraindicated.
• Keep the head in a midline position to promote venous drainage and minimize ICP.
• Avoid positions that increase intra-abdominal or intrathoracic pressure, as these can affect ICP.
• Monitor for signs of increased ICP, such as headache, vomiting, or changes in mental status, and report any concerning findings to the healthcare provider immediately.

 

✘Incorrect answer options:

Lying on the left side. After a supratentorial craniotomy, especially on the left side, lying on the surgical side can increase ICP and compromise the surgical site. It's generally safer to avoid this position.

With the neck flexed. Flexing the neck can impede venous outflow and increase ICP. It’s important to keep the neck in a neutral, midline position to facilitate proper drainage.

Supine on the left side. This phrase is confusing as "supine" means lying on the back, while "on the left side" means lying laterally. Neither supine nor lateral positioning on the surgical side is recommended post-craniotomy due to the risk of increasing ICP and disturbing the surgical site.

With extreme hip flexion. Extreme hip flexion can increase intra-abdominal pressure, which in turn can increase ICP. It is important to avoid positions that put unnecessary strain on the body and could affect cerebral circulation.

 

References

• Hickey, J. V. (2013). The Clinical Practice of Neurological and Neurosurgical Nursing. Wolters Kluwer Health/Lippincott Williams & Wilkins.
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answers:

Use gloves when emptying the patient’s bedpan. Using gloves when emptying the patient’s bedpan is essential to protect against contamination from radioactive materials that may be excreted in the patient's waste. This practice is crucial to minimize the risk of radiation exposure.

Keep all linens in the room until the implant is removed. Keeping all linens in the room until the implant is removed helps prevent the spread of radiation outside the patient's room. Linens may become contaminated with radioactive material, and containing them within the room reduces exposure to staff and other patients.

Wear a dosimeter badge while in the patient’s room. Wearing a dosimeter badge is important to monitor the cumulative radiation exposure of healthcare workers. This badge helps ensure that radiation exposure stays within safe limits, protecting the health and safety of the staff.

Wear a lead apron during direct patient care. Wearing a lead apron provides a barrier to reduce radiation exposure during direct patient care. This protective measure is important to minimize the risk of radiation to healthcare workers who need to be close to the patient.

Think of radiation safety measures like precautions for handling a hot stove. You wear oven mitts (gloves), keep potentially contaminated items close to the stove (linens in the room), use a thermometer to check heat levels (dosimeter badge), and wear an apron to protect from splashes (lead apron).

 

✘Incorrect answer option:

Assign the patient to a semi-private room at the end of the hallway. This option is incorrect because a patient with an internal radiation implant should be placed in a private room to prevent unnecessary radiation exposure to other patients. Isolation helps ensure that radiation safety protocols can be maintained effectively.

 

References

• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.
• Mosby's Medical, Nursing & Allied Health Dictionary. (2016). Elsevier.

EXPLANATION

 

✔Correct answer:

Psychosocial well-being. While psychosocial well-being is important in a comprehensive assessment, it is of least priority in the context of preparing Mr. Harris for a hernia repair in the ambulatory care unit. For a surgical procedure, the immediate focus should be on the patient's physiological status to ensure that he is medically stable for surgery. This includes assessing respiratory status, cardiovascular condition, and neurological status to identify any potential risks that could complicate anesthesia or the surgical procedure.

Preoperative assessments prioritize physiological stability to reduce the risk of complications during surgery. Respiratory status ensures that the patient can be safely intubated and ventilated. Cardiovascular condition is crucial to assess the risk of cardiac complications. While the neurological assessment may not be as directly relevant as the others, it still provides important information about the patient's overall health status.

Think of preparing for surgery like preparing a computer for a major update. Ensuring the computer’s power supply (cardiovascular system) and cooling system (respiratory system) are functioning properly is a higher priority than checking the software settings (psychosocial well-being) before starting the update.

While psychosocial assessments are part of holistic care, they are not the immediate priority in the preoperative period for a patient undergoing hernia repair. Focus should remain on physiological assessments to ensure the patient is in optimal condition for surgery.

• Conduct thorough respiratory assessments, including lung sounds, respiratory rate, and history of any respiratory conditions.
• Perform cardiovascular assessments, including blood pressure, heart rate, and history of cardiac conditions.
• Evaluate neurological status to ensure there are no issues that could complicate anesthesia or surgery.

 

✘Incorrect answer options:

Respiratory status. Ensuring the patient’s respiratory system is functioning well is crucial to avoid complications during anesthesia and postoperative recovery, making it a high priority.

Neurological assessment. While not as immediately critical as respiratory or cardiovascular assessments, the neurological assessment still provides important information about the patient's overall health status, which could impact anesthesia management.

Cardiovascular condition. Monitoring cardiovascular status is essential to prevent intraoperative and postoperative cardiac complications, making it a high priority in preoperative assessments.

 

References

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

A client who is on a ventilator. The client on a ventilator should be Nurse Davis's first priority. Clients on ventilators are critically dependent on the machine for breathing, and any malfunction or change in their condition can quickly become life-threatening. Immediate assessment and continuous monitoring are essential to ensure the ventilator is functioning correctly, the airway is secure, and the client is adequately oxygenated and ventilated.

Ventilated patients are at high risk for complications such as ventilator-associated pneumonia, accidental extubation, airway obstruction, or equipment malfunction. Early detection and intervention are crucial to prevent hypoxia and other potentially fatal complications.

Think of the ventilator as a car’s engine for a person who cannot breathe on their own. If the engine has issues, it must be addressed immediately to prevent the car from stalling, similar to ensuring the patient’s survival.

Nurse Davis should promptly assess the ventilated client, ensuring the ventilator settings are correct, the airway is clear, and there are no signs of respiratory distress.

• Check the ventilator settings and alarms to ensure they are correctly set for the patient’s needs.
• Assess the client’s respiratory status, including rate, rhythm, and effort of breathing, as well as oxygen saturation levels.
• Listen for breath sounds to ensure both lungs are being ventilated properly and there are no signs of atelectasis or pneumothorax.
• Inspect the endotracheal tube for proper placement and securement.
• Monitor for any signs of discomfort, distress, or changes in the client’s condition that may indicate a problem.

 

✘Incorrect answer options:

A client who is in skeletal traction. While this client requires regular monitoring to ensure proper alignment and to prevent complications such as pressure sores or deep vein thrombosis, they are generally more stable than a ventilated client.

A postoperative client getting ready for discharge. This client is likely stable and nearing the end of their hospital stay, making them a lower priority compared to a ventilated patient.

A client newly admitted with gastroenteritis. While this client needs assessment and care, their condition is generally less immediately life-threatening compared to the needs of a ventilated patient. Hydration and monitoring are important but can be attended to after ensuring the ventilated client is stable.

 

References

• Urden, L. D., Stacy, K. M., & Lough, M. E. (2018). Critical Care Nursing: Diagnosis and Management. Elsevier.
• Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Disconnecting the IV tubing from the catheter in the vein. Disconnecting the IV tubing from the catheter in the vein is an action that Nurse Patel should avoid. This practice increases the risk of introducing infection into the IV system and can lead to complications such as phlebitis or bloodstream infections. It can also cause disruption of the IV infusion, leading to potential issues with fluid and medication administration.

Maintaining the integrity of the IV system is crucial to prevent infections. Every time the IV system is opened, it creates an opportunity for pathogens to enter, which is particularly risky for patients with compromised health.

Think of the IV system as a sealed pipeline delivering clean water. Disconnecting the pipeline introduces contaminants, just as opening the IV system increases the risk of infection.

To safely change Mr. Lewis's gown while maintaining the integrity of the IV system, Nurse Patel should use gowns with snap closures at the sleeves or follow proper techniques for threading the IV bag and tubing through the gown sleeves.

• Choose a gown with snap closures at the sleeves, allowing easy removal and dressing without disrupting the IV line.
• If using a regular gown, carefully thread the IV bag and tubing through the gown sleeve first, followed by the client’s arm, to avoid disconnection.
• Reassess the IV flow rate and site after changing the gown to ensure it remains intact and functional.
• Ensure the IV tubing is not kinked or pulled during the process, maintaining proper infusion flow.

 

✘Incorrect answer options:

Opting for a gown with snap closures at the sleeves. This is a safe and practical option that facilitates gown changes without disturbing the IV line, reducing the risk of infection and maintaining the integrity of the infusion.

Reassessing the IV flow rate right after changing the gown. This is a necessary and prudent action to ensure that the IV infusion continues properly after the gown change. It helps in early detection of any issues that might have arisen during the process.

Threading the IV bag and tubing through the sleeve, then the client’s arm. This technique, when done carefully, is a standard practice to change the gown without disconnecting the IV line, thus maintaining the closed system and reducing infection risk.

 

References

• Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical Nursing Skills and Techniques. Elsevier.
• Weinstein, S. M., & Hagle, M. E. (2014). Plumer's Principles and Practice of Infusion Therapy. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Ask about the client's emotions that could impact coping. In the aftermath of a traumatic event like a house fire and the loss of a neighbor, it is essential to address the emotional and psychological well-being of the client. By asking Mr. Johnson about his emotions, Nurse Thompson can gain insight into how he is processing the trauma, identify any feelings of guilt, grief, or distress, and determine how these emotions might affect his coping mechanisms. Understanding his emotional state is a critical step in providing comprehensive care and developing an appropriate support plan.

Addressing Mr. Johnson's emotions helps in identifying signs of acute stress disorder or post-traumatic stress disorder (PTSD), which are common after traumatic events. It allows for early intervention and support, which can significantly impact his long-term mental health and recovery.

Imagine a dam holding back water (emotions). If the dam is at risk of breaking, it’s crucial to assess the pressure (emotional impact) to prevent a flood (mental health crisis). Addressing the pressure helps manage and reinforce the dam (emotional stability).

Nurse Thompson should employ active listening and empathetic communication techniques to help Mr. Johnson express his feelings and concerns. This can facilitate a therapeutic relationship and create a safe environment for emotional healing.

• Use open-ended questions to encourage Mr. Johnson to talk about his feelings and experiences.
• Validate his emotions and provide reassurance that it is normal to have strong reactions after such a traumatic event.
• Offer resources for psychological support, such as counseling services or support groups.
• Monitor for signs of depression, anxiety, or PTSD and communicate any concerns to the healthcare team for further evaluation and intervention.
• Encourage healthy coping mechanisms, such as talking to loved ones, engaging in relaxing activities, and maintaining a routine.

 

✘Incorrect answer options:

Assess the client's functional abilities. While assessing functional abilities is important, it does not directly address the emotional and psychological impact of the traumatic event, which is crucial for holistic care.

Evaluate the client's risk for self-harm. Evaluating the risk for self-harm is important if there are indications of severe distress or suicidal ideation. However, the initial step should be to understand his emotional state comprehensively, which can guide further assessment and intervention needs.

Explore the client's understanding of what caused the neighbor's death. While it might be important to discuss the event itself at some point, focusing on the client's immediate emotional responses and coping mechanisms takes precedence. Delving into details about the neighbor's death may not be helpful initially and could exacerbate distress.

 

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Videbeck, S. L. (2020). Psychiatric-Mental Health Nursing. Wolters Kluwer.

EXPLANATION

 

✔Correct answers:

An early morning cough. Chronic bronchitis is often characterized by a persistent, productive cough, especially in the early morning. This is due to the accumulation of mucus in the airways overnight, which the body tries to clear upon waking.

Production of purulent mucus. The production of purulent (pus-containing) mucus is a common sign of chronic bronchitis. This indicates the presence of infection or chronic inflammation in the bronchial tubes.

Mild bouts of difficulty breathing. Chronic bronchitis often leads to mild bouts of difficulty breathing or shortness of breath due to airway obstruction from mucus and inflammation.

Think of chronic bronchitis like having a blocked and swollen garden hose (bronchial tubes). The hose produces sputtering and spitting water (coughing with mucus) especially when first turned on in the morning, and it flows less efficiently (difficulty breathing) because it's clogged (mucus and inflammation).

Nurse Sarah should document these symptoms and report them to the healthcare provider to confirm the diagnosis and start appropriate management for chronic bronchitis.

• Perform a thorough respiratory assessment, including lung sounds, respiratory rate, and effort.
• Collect a sputum sample if necessary to analyze the type of mucus and detect any infections.
• Monitor oxygen saturation levels to assess the degree of respiratory impairment.
• Educate the patient about the importance of smoking cessation if applicable, as smoking is a major cause of chronic bronchitis.
• Develop a care plan that includes interventions to manage symptoms, such as bronchodilators, corticosteroids, and pulmonary hygiene techniques.

 

✘Incorrect answer options:

Minimal mucus production. Chronic bronchitis typically involves increased mucus production. Minimal mucus production would not support this diagnosis.

Significant weight loss. While significant weight loss can occur in severe cases of chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis, it is not a primary sign of chronic bronchitis itself. The hallmark symptoms are related to mucus production and respiratory difficulties.

 

References

• GOLD (Global Initiative for Chronic Obstructive Lung Disease). (2021). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Retrieved from https://goldcopd.org/
• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.

EXPLANATION

 

✔Correct answer:

Numbness and tingling in the toes. Numbness and tingling in the toes are significant findings that may indicate nerve compression or compromised circulation, potentially due to compartment syndrome. Compartment syndrome is a serious condition that occurs when increased pressure within a confined space compromises blood flow and nerve function within that space. It is a medical emergency that requires immediate intervention to prevent permanent damage to muscles and nerves.

Compartment syndrome results from increased pressure within the muscle compartments, which can occur after fractures, especially if there is significant swelling or a tight cast. If not promptly treated, it can lead to ischemia and irreversible damage to the muscles and nerves.

Imagine the muscle compartment as a tightly sealed suitcase. If you keep adding items (swelling or tight cast) and it gets overfilled, the pressure inside builds up, and the items inside (muscles and nerves) get squished and damaged. Removing some items or loosening the suitcase is necessary to prevent damage.

Nurse Tom should promptly report the numbness and tingling to the physician so that the cast can be assessed and possibly adjusted or removed to relieve pressure. Immediate intervention is critical to prevent the development of compartment syndrome.

• Elevate the affected limb to reduce swelling while awaiting further instructions.
• Regularly assess and document the neurovascular status of the affected limb, including color, temperature, pulses, capillary refill, and sensation.
• Monitor for increasing pain that is not relieved by pain medication, which can also be a sign of compartment syndrome.
• Educate the patient about the signs and symptoms of compartment syndrome and the importance of reporting them immediately.

 

✘Incorrect answer options:

Pain under the cast. While pain is a common finding after fracture and cast application, it does not specifically indicate an urgent complication unless it is severe, unrelenting, and disproportionate to the injury.

Toes are warm. Warm toes are a positive sign indicating good circulation and do not suggest any immediate complications.

Pedal pulses are weak and fast. While weak and fast pedal pulses are concerning and need to be monitored, they do not provide as direct a sign of potential nerve compression or compartment syndrome as numbness and tingling in the toes.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Dutton, M. (2016). Dutton's Orthopaedic Examination, Evaluation, and Intervention. McGraw-Hill Education.

EXPLANATION

 

✔Correct answer:

The client’s lab results show normal electrolyte levels. For an elderly client with bulimia, the best indicator that the nutritional care plan has been effective is the normalization of electrolyte levels. Bulimia often leads to severe electrolyte imbalances due to repeated episodes of binge eating and purging (e.g., vomiting, laxative abuse), which can have critical health implications, especially in elderly patients who may already have compromised health. Normal electrolyte levels suggest that the client is achieving a more balanced intake of nutrients and fluids, and that the harmful behaviors have decreased significantly.

Electrolyte imbalances in bulimia can lead to serious complications, such as cardiac arrhythmias, muscle weakness, and seizures. By achieving normal electrolyte levels, the client's body is more likely to be functioning properly, indicating a positive response to the treatment plan.

Think of electrolyte levels as the fuel gauge in a car. When the gauge shows full, the car is ready to function optimally. Similarly, normal electrolyte levels indicate that the body has the necessary 'fuel' to operate healthily.

Nurses should continue to monitor the client’s electrolyte levels regularly and provide ongoing support to maintain nutritional balance.

• Encourage a balanced diet and provide nutritional counseling to prevent relapse into disordered eating behaviors.
• Monitor for signs of electrolyte imbalance and address any issues promptly.
• Continue psychosocial support, such as therapy sessions, to address underlying psychological issues.
• Educate the client and family about the importance of maintaining normal electrolyte levels and the risks associated with bulimia.

 

✘Incorrect answer options:

The client reports a decrease in episodes of binge eating and purging. While a reduction in binge eating and purging is a positive sign, it does not directly measure the client's nutritional status or physical health improvements.

The client has maintained a stable weight for the past three months. Stable weight is important but does not necessarily reflect the overall effectiveness of the care plan in addressing the metabolic disturbances caused by bulimia.

The client participates in group therapy sessions twice a week. Participation in therapy is beneficial for psychological support and long-term management of bulimia, but it does not directly indicate the success of nutritional interventions.

 

References

• Mehler, P. S., & Brown, C. (2015). Anorexia nervosa - medical complications. Journal of Eating Disorders, 3, 11.
• Mitchell, J. E., & Peterson, C. B. (2020). Assessment and Treatment of Eating Disorders: An Integrative Approach to Etiology and Evidence-Based Clinical Practice. Guilford Publications.

EXPLANATION

 

✔Correct answer:

Laryngeal edema. In patients with facial burns, especially those caused by explosions, the primary concern is the potential for laryngeal edema, which can lead to airway obstruction. Burns in the facial area can cause significant swelling, and inhalation of hot gases or smoke can further exacerbate this condition, leading to swelling of the airway tissues. Prompt assessment and intervention are crucial to ensure the patient's airway remains open and to prevent respiratory distress or failure.

Laryngeal edema occurs due to inflammation and swelling of the laryngeal tissues. This can be life-threatening because it can rapidly lead to compromised airway patency, making it difficult or impossible for the patient to breathe. Early signs may include hoarseness, stridor, or difficulty breathing, necessitating immediate medical attention to secure the airway.

Imagine the airway as a narrow tunnel. If debris (swelling) starts to block the tunnel, cars (air) can't pass through easily, leading to a traffic jam (breathing difficulty). Clearing the debris promptly is essential to keep traffic flowing smoothly.

Nurses should closely monitor the patient for signs of airway compromise and be prepared to assist with emergency airway management, such as intubation, if necessary.

• Continuously assess the patient's respiratory status, including rate, depth, and effort of breathing.
• Listen for abnormal breath sounds such as stridor or wheezing.
• Monitor for signs of increasing respiratory distress, such as cyanosis or use of accessory muscles.
• Prepare for possible interventions, such as administering humidified oxygen or assisting with intubation if indicated.
• Communicate promptly with the healthcare team regarding any changes in the patient's condition.

 

✘Incorrect answer options:

Hypovolemia. While hypovolemia is a significant concern in burn patients due to fluid loss, it is more likely to develop over time as fluids shift from the vascular space. In the immediate period following a burn injury, airway management takes precedence over fluid management.

Hypernatremia. Hypernatremia is not a common immediate concern following burns. Electrolyte imbalances, including hypernatremia, may develop later but are not the primary focus in the acute phase of burn management.

Hyperkalemia. Hyperkalemia can occur in burn patients due to cell damage and the release of intracellular potassium, but it is not the primary immediate concern. The immediate threat to life is airway compromise due to laryngeal edema.

 

References

• Cowan, M. L., & Shapiro, B. A. (2019). Burns. In L. H. Thomas (Ed.), Critical Care Nursing: Diagnosis and Management (8th ed., pp. 951-976). Elsevier.
• Sherwood, L. (2015). Human Physiology: From Cells to Systems (9th ed.). Cengage Learning.

EXPLANATION

 

✔Correct answer:

Inform the physician of the mother's refusal. When a parent refuses a medical treatment for their child, it is critical for the nurse to respect the parent's wishes and promptly inform the physician. The physician needs to be aware of the refusal to address the situation appropriately, discuss alternative treatments, and assess the need for any further action, including possible legal steps if the child's life is at risk. This approach ensures that the healthcare team respects the family's beliefs while prioritizing the child's health and safety.

The healthcare team must navigate the ethical dilemma of respecting parental autonomy while ensuring the child's right to life-saving treatment. Informing the physician allows for a comprehensive discussion with the family and possibly involving an ethics committee or social services to mediate and find a resolution.

Think of a nurse as a navigator on a ship, the physician as the captain, and the child as the passenger. If the navigator (nurse) encounters an obstacle (the mother's refusal), they must inform the captain (physician) immediately. The captain can then chart the best course of action, considering all factors and ensuring the passenger's (child's) safety and well-being, while respecting the situation's complexities.

Nurses must act as advocates for their patients, ensuring that the patient's needs are communicated effectively to the entire healthcare team, including the physician.

• Document the mother's refusal and the details of the conversation in the patient's medical record.
• Notify the physician immediately to discuss the refusal and potential alternative treatments.
• Support the mother by providing information and addressing her concerns while respecting her beliefs.
• Consider involving a social worker, chaplain, or patient advocate to support the family and facilitate communication.

 

✘Incorrect answer options:

Ask the mother to leave while the blood transfusion is in progress. This action disregards the mother's rights and beliefs, potentially causing significant distress and violating ethical principles. The mother’s consent is legally required for the transfusion.

Encourage the mother to reconsider her decision. While it is important to provide information, pressuring the mother to change her decision can create conflict and mistrust. It is better to inform the physician and involve them in the discussion.

Explain the potential consequences of not receiving the treatment. Although providing information about the consequences is important, it should be done in conjunction with the physician. The primary responsibility is to inform the physician so a collaborative approach can be taken to address the situation.

 

References

• Butts, J. B., & Rich, K. L. (2019). Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.
• Silva, D. S., & Smith, M. J. (2015). Ethical decision-making in nursing and healthcare: The symphonological approach. Springer Publishing Company.

EXPLANATION

 

✔Correct answer:

She inserts a Foley catheter. Magnesium sulfate is commonly used in the management of preeclampsia to prevent seizures (eclampsia). One of the critical side effects of magnesium sulfate therapy is its effect on renal function. It is essential to monitor urine output closely because magnesium is excreted through the kidneys, and reduced urine output can lead to magnesium toxicity. Inserting a Foley catheter allows for accurate measurement of urine output, ensuring the patient's renal function is adequate and reducing the risk of magnesium toxicity.

Monitoring urine output is vital in patients receiving magnesium sulfate to detect early signs of toxicity, such as diminished deep tendon reflexes, respiratory depression, and cardiac arrhythmias. Accurate measurement through a Foley catheter helps in the timely adjustment of the magnesium sulfate dosage to maintain therapeutic levels and prevent complications.

Think of the kidneys as a filtration system for a swimming pool. If the filter gets clogged and water (urine) flow decreases, the pool (body) will accumulate debris (toxins). A Foley catheter is like a gauge that helps ensure the filter is working properly by monitoring the flow rate.

Nurses must be vigilant in monitoring patients on magnesium sulfate for signs of toxicity and ensure appropriate interventions are in place to manage potential side effects.

• Regularly check and document urine output to assess kidney function.
• Monitor deep tendon reflexes and respiratory status to detect early signs of magnesium toxicity.
• Keep calcium gluconate readily available as an antidote for magnesium toxicity.
• Educate the patient about the purpose of the Foley catheter and the importance of monitoring urine output.

 

✘Incorrect answer options:

She places a sign over the bed instructing not to check blood pressure in the right arm. This action may be relevant in certain situations (e.g., after a mastectomy or with an arteriovenous fistula), but it does not address the potential side effects of magnesium sulfate therapy in preeclampsia.

She places a padded tongue blade at the bedside. This is an outdated practice and not recommended. Modern seizure precautions do not include placing objects in the patient's mouth. Instead, focus should be on safety measures like side rail padding and positioning.

She darkens the room. While reducing environmental stimuli can help manage patients with preeclampsia by decreasing the risk of seizures, it does not directly address the side effects of magnesium sulfate therapy. Monitoring urine output is more specific to the management of magnesium toxicity.

 

References

• Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S., Hoffman, B. L., Casey, B. M., & Spong, C. Y. (2018). Williams Obstetrics. McGraw-Hill Education.
• Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2016). Maternity & Women's Health Care. Elsevier.

EXPLANATION

 

✔Correct answer:

A cup of yogurt. Yogurt is an excellent source of calcium, which is essential for the development of strong bones and teeth, as well as the proper function of muscles and nerves in both the pregnant client and the developing fetus. A single cup of yogurt typically contains about 300-400 mg of calcium, making it one of the best options for meeting daily calcium needs during pregnancy.

During pregnancy, adequate calcium intake is crucial to support the increased demands of the growing fetus. If the dietary intake of calcium is insufficient, the body will draw calcium from the mother's bones, which can compromise her bone density and increase the risk of osteoporosis later in life.

Think of calcium as building blocks for a house. Just as a house needs sturdy bricks to maintain its structure, a pregnant woman needs adequate calcium to build strong bones for herself and her baby.

Nurses should educate pregnant clients about the importance of calcium and recommend including high-calcium foods like dairy products, leafy greens, and fortified foods in their diet. They should also discuss the potential need for calcium supplements if dietary intake is insufficient.

• Encourage the consumption of dairy products such as milk, cheese, and yogurt.
• Suggest non-dairy calcium sources like fortified plant-based milk and orange juice, almonds, and leafy green vegetables.
• Advise the client to consult with a healthcare provider before starting any supplements.

 

✘Incorrect answer options:

A granola bar. While some granola bars may be fortified with calcium, they generally do not provide as much calcium as a cup of yogurt. They may also contain added sugars and other ingredients that do not contribute to calcium intake.

A bran muffin. Bran muffins are a good source of fiber but are not typically high in calcium. They are not a primary source of calcium compared to dairy products like yogurt.

A glass of fruit juice. Unless fortified, fruit juice generally contains little to no calcium. Even fortified fruit juice often provides less calcium per serving than dairy products like yogurt.

 

References

• Mahan, L. K., Raymond, J. L., & Krause, M. V. (2016). Krause's Food & the Nutrition Care Process. Elsevier Health Sciences.
• Ward, E. (2017). Optimizing nutrition in pregnancy and lactation: the evidence. Proceedings of the Nutrition Society, 76(3), 349-356.

EXPLANATION

 

✔Correct answer:

Monitor for signs of abnormal bleeding. A Protime (PT) of 120 seconds is significantly elevated, indicating that the patient’s blood is taking an excessively long time to clot. Sodium warfarin (Coumadin) is an anticoagulant, and a PT this high suggests the patient is at a high risk for bleeding. Therefore, the most crucial intervention is to monitor for signs of abnormal bleeding, as this represents an immediate and potentially life-threatening complication.

Warfarin inhibits the synthesis of vitamin K-dependent clotting factors, which prolongs the PT and International Normalized Ratio (INR). Therapeutic levels are typically monitored to ensure they are within a safe range (e.g., an INR of 2-3 for most indications). A PT of 120 seconds suggests over-anticoagulation, necessitating immediate attention to prevent serious bleeding events.

Imagine the blood clotting process as a traffic system where stoplights (clotting factors) regulate the flow of cars (blood). If all the stoplights turn red (high PT), cars will come to a standstill, causing a traffic jam (risk of bleeding) and making it hard for any car to move (blood to clot). Monitoring and ensuring some stoplights stay green is crucial to maintain a balanced flow and prevent a complete halt (excessive bleeding).

Monitoring for abnormal bleeding involves frequent assessments for:

• Bruising or hematomas.
• Nosebleeds.
• Blood in urine or stool.
• Prolonged bleeding from cuts or injection sites.
• Signs of internal bleeding, such as abdominal pain or swelling.

Additional steps include:

• Educate the patient on avoiding activities that could cause injury.
• Adjust the warfarin dosage as per physician's orders based on the PT/INR results.
• Administer vitamin K or other reversal agents as prescribed to counteract the excessive anticoagulation.
• Monitor vital signs closely for signs of hemodynamic instability.

 

✘Incorrect answer options:

Expect an increase in the Coumadin dosage. This is incorrect because a PT of 120 seconds indicates over-anticoagulation, meaning the dosage of Coumadin should likely be decreased, not increased.

Educate the patient about the medication therapy. While patient education is always important, it is not the most critical intervention when the patient is at immediate risk for bleeding. Immediate actions to ensure patient safety take precedence.

Enhance the frequency of neurological assessments. While neurological assessments are crucial if there is a suspicion of intracranial bleeding, they are not the most comprehensive approach to managing the risk of bleeding due to an elevated PT. Monitoring for all potential bleeding sites is more critical.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Hirsh, J., Fuster, V., Ansell, J., & Halperin, J. L. (2003). "American Heart Association/American College of Cardiology Foundation guide to warfarin therapy." Circulation, 107(12), 1692-1711.

EXPLANATION

 

✔Correct answer:

Cover the insertion site with Vaseline gauze. When a chest tube is accidentally dislodged, the immediate priority is to prevent air from entering the pleural space, which could lead to a pneumothorax. Covering the insertion site with Vaseline gauze creates an airtight seal, which helps to prevent the development of a pneumothorax or tension pneumothorax by stopping air from being sucked into the chest cavity during inhalation.

A chest tube is inserted to remove air, blood, or fluid from the pleural space to help the lungs expand properly. If the tube is dislodged, air can enter the pleural space, which may collapse the lung (pneumothorax) or create pressure on the heart and other lung (tension pneumothorax), potentially leading to life-threatening complications.

Imagine a punctured tire that needs to be patched immediately to stop the air from escaping. Similarly, the chest insertion site needs to be sealed quickly to prevent air from entering and causing further complications.

After applying the Vaseline gauze, Nurse Laura should:

• Secure the Gauze: Tape the gauze on three sides to allow air to escape but not re-enter the pleural space.
• Notify the Physician: Inform the physician immediately about the dislodged chest tube.
• Monitor the Patient: Continuously monitor the patient’s respiratory status, oxygen saturation, and vital signs for any signs of respiratory distress.
• Prepare for Reinsertion: Assist in preparing for the possible reinsertion of the chest tube or other necessary interventions as directed by the physician.

 

✘Incorrect answer options:

Request a chest x-ray. While a chest x-ray is necessary to assess the lung's condition after the chest tube is dislodged, it is not the immediate action to take. The priority is to seal the insertion site to prevent air from entering the pleural space.

Reinsert the chest tube. Reinserting a chest tube is a procedure that requires sterile technique and should be performed by a physician or trained healthcare professional, not the nurse. Attempting to reinsert the tube without proper preparation and sterile conditions could lead to infection and other complications.

Notify the physician immediately. Although notifying the physician is important, the first action should be to secure the insertion site with Vaseline gauze to prevent air from entering the pleural space. Immediate intervention to seal the site is critical before contacting the physician.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Morris, P. J. (2018). Chest Tube Management. Critical Care Nurse, 38(1), e9-e18.

EXPLANATION

 

✔Correct answer:

Call for a rapid response team. When a patient becomes unresponsive and displays signs of hypotension (90/40 mmHg), it is crucial to call for immediate assistance. The rapid response team (RRT) consists of healthcare professionals trained to quickly assess and manage emergent situations. This is the most appropriate first action because it ensures that the patient receives timely and comprehensive care, which can include advanced airway management, resuscitation, and other life-saving interventions.

A sudden drop in blood pressure and loss of consciousness can indicate several critical conditions such as hemorrhage, shock, or cardiac events. In the context of a recent laryngectomy, airway issues, bleeding, or other postoperative complications are possible. The RRT is equipped to handle these scenarios promptly.

Imagine you're driving and your car suddenly stops working on a busy highway. The best immediate action is to call roadside assistance (rapid response team) who can quickly come and address the issue before it becomes more dangerous, rather than trying to fix the car yourself without proper tools or knowledge.

After calling the RRT, Nurse Amy should continue to monitor the patient’s vital signs, ensure the airway is clear, and be prepared to assist the team with any necessary interventions. Staying with the patient and providing continuous assessment is crucial until the RRT arrives.

 

✘Incorrect answer options:

Perform chest compressions immediately. Chest compressions are indicated if the patient is in cardiac arrest (no pulse and not breathing). The scenario does not specify that the patient is pulseless or not breathing, only that they are unresponsive and hypotensive. The first step is to get help from the RRT.

Check the patient's airway for obstructions. While checking the airway is important, the priority is to get immediate help from the RRT to ensure comprehensive assessment and intervention. After calling the RRT, checking the airway can be done if there are signs of airway obstruction.

Administer IV fluids to stabilize blood pressure. Administering IV fluids can be part of the treatment plan for hypotension, but it should be done under the direction of the RRT or physician. The immediate priority is to summon the RRT to provide a full assessment and initiate appropriate interventions.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• American Heart Association. (2020). Advanced Cardiovascular Life Support (ACLS) Provider Manual. AHA.

EXPLANATION

 

✔Correct answer:

Request the family take the fruit home. Patients with low white blood cell (WBC) counts, especially those in the organ transplant unit, are at a higher risk of infection due to immunosuppression. Fresh fruit, even if washed, can harbor bacteria, fungi, or other pathogens that pose a significant risk to immunocompromised patients. Therefore, the safest course of action is to request that the family take the fruit home to minimize the risk of infection.

A low WBC count indicates leukopenia, which compromises the patient's immune system, making them more susceptible to infections. This is particularly critical in transplant patients who are typically on immunosuppressive medications to prevent organ rejection, further reducing their ability to fight off infections.

Imagine the patient’s immune system as a security team that is very short-staffed (low WBC count). Allowing fresh fruit, which can carry hidden threats (bacteria and fungi), into their environment is like leaving the doors open in a high-risk area. It's safer to remove the potential threats altogether.

Nurse Riley should explain to the family the importance of protecting the patient from potential infections and suggest alternative gifts that are safe and appropriate for the patient's condition, such as pre-packaged snacks approved by the hospital's dietary guidelines, books, or other non-food items.

 

✘Incorrect answer options:

Permit the patient to keep the fruit. Allowing the patient to keep the fruit without any precautions does not address the risk of infection from potential pathogens on the fruit.

Place the fruit on the bedside table for the patient's convenience. Simply placing the fruit on the bedside table still exposes the patient to the risk of infection from pathogens that might be present on the fruit's surface.

Offer to wash the fruit for the patient. While washing fruit can remove some surface pathogens, it does not eliminate all risks, especially for immunocompromised patients. Additionally, certain fruits can still harbor bacteria or fungi internally, which washing will not remove.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Centers for Disease Control and Prevention. (2020). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep, 49(RR-10), 1-128.

EXPLANATION

 

✔Correct answer:

Enjoys playing football. Osteogenesis imperfecta (OI) is a genetic disorder characterized by brittle bones that are prone to fractures. Engaging in high-impact sports such as football poses a significant risk for fractures and other injuries due to the physical contact and high-impact nature of the sport. Therefore, this information raises the most concern as it directly increases the likelihood of severe injury in a patient with OI.

Osteogenesis imperfecta results from mutations in the genes responsible for producing collagen, a crucial protein for bone strength and structure. The bones of individuals with OI are fragile and can break easily, even with minimal trauma. This condition requires careful management to prevent fractures and maintain mobility.

Imagine bones in OI are like delicate china plates, while normal bones are like sturdy ceramic plates. If you drop both, the china (OI bones) is much more likely to shatter. Now, picture playing football with these plates - the risk of breakage for the china plates would be extremely high, just as it is for someone with OI playing football.

The nurse should provide education on safe activities and recommend low-impact exercises that strengthen muscles and improve bone density without risking fractures. Suggestions might include swimming or walking. The nurse should also discuss protective measures and possibly involve a physical therapist to design a suitable exercise regimen.

 

✘Incorrect answer options:

Consumes multiple carbonated drinks daily. While excessive consumption of carbonated drinks is not ideal due to the potential for high sugar intake and its possible association with lower calcium levels, it is not as immediately dangerous as engaging in a high-impact sport. This can be addressed with dietary counseling to improve overall bone health.

Has two sisters with sickle cell trait. Having family members with sickle cell trait is not directly related to the management of osteogenesis imperfecta. While it's important to understand the patient's full medical and family history, this information does not raise immediate concern for injury or complications associated with OI.

Uses acetaminophen for pain management. Acetaminophen is commonly used for pain management in patients with OI. It is a safe option for pain control when used as directed, and it does not pose a significant concern compared to the risk of physical injury from playing football.

 

References

• Benson, J. E. (2020). "Osteogenesis Imperfecta." In: Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Brizola, E., Shapiro, J. R. (2020). "Bone Health and Osteogenesis Imperfecta." Clinics in Perinatology, 47(1), 153-167.

EXPLANATION

 

✔Correct answer:

Deficit in fluid volume. The client's vital signs—low blood pressure (80/34), elevated pulse rate (120), and normal respiratory rate (20)—suggest hypovolemia, which is a critical deficit in fluid volume. This condition can be caused by blood loss, as might occur in trauma such as a car accident. The body attempts to compensate for the low blood volume by increasing the heart rate to maintain adequate circulation to vital organs. The priority for the nurse should be to recognize this deficit and address it promptly to prevent shock and further complications.

Hypovolemia is a state of decreased blood volume, which can lead to inadequate perfusion of tissues and organs. This condition can quickly progress to hypovolemic shock if not treated promptly. Signs of hypovolemia include low blood pressure, tachycardia, and signs of poor perfusion such as cold, clammy skin.

Imagine your blood volume as the fuel in a car. If there's a significant leak in the fuel tank (blood loss), the car (body) won't have enough fuel (blood) to keep the engine running smoothly (organ perfusion). The car might try to compensate by using the remaining fuel more efficiently, but eventually, it will stall without an adequate fuel supply.

The nurse should immediately implement measures to manage the fluid volume deficit. This involves:

• Ensuring the airway is clear and providing oxygen as needed.
• Initiating IV access to administer fluids rapidly, such as isotonic saline or lactated Ringer's solution.
• Monitoring vital signs frequently to assess the patient's response to fluid resuscitation.
• Preparing for possible blood transfusion if there is significant blood loss.
• Assessing for sources of bleeding and applying pressure or dressings as needed.

 

✘Incorrect answer options:

Altered cerebral tissue perfusion. While altered cerebral tissue perfusion is a serious concern, the client's vital signs more immediately suggest hypovolemia. The low blood pressure and high pulse rate need to be stabilized to ensure adequate overall perfusion, including cerebral perfusion.

Ineffective airway clearance. The client's respiratory rate of 20 is within normal limits, and there is no indication from the information provided that the airway is compromised. Therefore, this is not the priority diagnosis.

Altered sensory perception. There is no information given that indicates altered sensory perception. The vital signs suggest a more pressing issue of fluid volume deficit that must be addressed urgently.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Measuring the abdominal girth on a daily basis. The most effective method for early detection of ascites is to measure the abdominal girth on a daily basis. This approach allows for the objective monitoring of any increases in abdominal size, which can indicate the accumulation of fluid in the peritoneal cavity. Daily measurements can provide a consistent and quantitative way to detect subtle changes over time, allowing for early intervention and management.

Ascites is the accumulation of fluid in the peritoneal cavity, often due to liver cirrhosis, heart failure, or malignancies. It results from increased pressure in the portal vein and decreased albumin levels, leading to fluid leakage from blood vessels into the abdominal cavity. Measuring abdominal girth at the same anatomical location each day (usually at the level of the umbilicus) provides a reliable indicator of fluid accumulation.

Think of the abdominal cavity as a balloon. If you want to know if the balloon is filling up with water, you would measure its circumference regularly. This consistent measurement helps you detect even small increases in the amount of water inside the balloon.

To accurately measure abdominal girth, Nurse Kelly should:

• Ensure the patient is in the same position each time the measurement is taken (preferably standing or lying flat).
• Use a non-stretchable tape measure and measure at the level of the umbilicus.
• Record the measurement at the same time each day, ideally before breakfast to avoid variations due to food intake.
• Monitor for trends in the measurements to detect any increases that may indicate fluid accumulation.
• Educate the patient about the importance of these measurements and how they can assist in managing their condition.

 

✘Incorrect answer options:

Observing the abdomen for any signs of enlargement. While visual observation is important, it is subjective and can be less accurate for early detection of ascites compared to daily girth measurements, which provide quantitative data.

Performing bimanual palpation to check for hepatomegaly. Bimanual palpation is useful for detecting an enlarged liver, which can be a sign of liver disease, but it is not specific for detecting ascites. Hepatomegaly can be present without ascites.

Checking for the presence of a fluid wave. The fluid wave test is a physical examination technique used to detect larger volumes of ascitic fluid. It is less effective for detecting small amounts of fluid and is more subjective compared to daily girth measurements.

 

References

• Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Alteration in nutrition. Pancreatic cancer often significantly affects the client's nutritional status. The pancreas plays a crucial role in digestion by producing enzymes that aid in the breakdown of nutrients. When the pancreas is compromised, as in the case of pancreatic cancer, the production of these enzymes can be insufficient, leading to malabsorption and nutritional deficiencies. Additionally, symptoms such as anorexia, nausea, vomiting, and early satiety are common in pancreatic cancer patients, further contributing to poor nutritional intake.

The pancreas has both endocrine and exocrine functions. In pancreatic cancer, the tumor can obstruct the pancreatic ducts, impairing the release of digestive enzymes into the small intestine. This results in malabsorption, particularly of fats and fat-soluble vitamins. Weight loss and cachexia are prevalent issues due to the body's inability to properly digest and absorb nutrients.

Think of the pancreas as a chef preparing food for the body. If the chef is unable to cook properly (due to the cancer), the body cannot get the necessary nutrients from the food, leading to poor health and weight loss.

Nurse Rachel should prioritize interventions that support the client’s nutritional status. This includes assessing the client's dietary intake, monitoring weight, providing nutritional supplements, and working with a dietitian to create an individualized meal plan. Enzyme replacement therapy may also be necessary to aid in digestion.

• Assess dietary intake and monitor weight regularly.
• Collaborate with a dietitian to develop an appropriate nutritional plan.
• Provide small, frequent, nutrient-dense meals to combat anorexia and early satiety.
• Administer pancreatic enzyme supplements as prescribed to aid digestion.
• Monitor for signs of malnutrition and address any deficiencies promptly.

 

✘Incorrect answer options:

Alteration in bowel elimination. While bowel elimination issues, such as constipation or diarrhea, can occur in pancreatic cancer, they are typically secondary to nutritional problems or treatment side effects. They are important but not the primary concern.

Alteration in skin integrity. Skin integrity issues, such as pressure ulcers, can arise due to immobility or poor nutritional status, but they are not the primary concern in the initial stages of managing pancreatic cancer. Proper nutrition can help prevent these complications.

Ineffective individual coping. Ineffective coping is a significant concern in patients with cancer due to the psychological impact of the diagnosis. However, ensuring adequate nutrition is more immediately critical to the client's overall physical health and ability to cope with treatment and disease progression.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Increase the rate of the IV infusion. Hypotension is a common side effect of epidural anesthesia due to the sympathetic blockade, which leads to vasodilation and decreased venous return to the heart. Increasing the rate of the IV infusion, typically with a crystalloid solution, helps to increase the circulating blood volume, thereby improving venous return and cardiac output, which can counteract the hypotensive effect.

Epidural anesthesia works by blocking nerve impulses in the lower spinal segments. This blockade affects the sympathetic nerves that normally constrict blood vessels. When these nerves are blocked, vasodilation occurs, leading to a drop in blood pressure. Administering IV fluids helps to expand the intravascular volume, which supports blood pressure.

Imagine the circulatory system as a garden hose system. If the pressure in the hose drops (hypotension), you can increase the water flow (IV fluids) to restore the pressure, ensuring the water reaches all areas of the garden (body tissues).

Immediate intervention is crucial to manage hypotension effectively. In addition to increasing the IV infusion rate, Nurse Emma should monitor the client's vital signs, provide oxygen if needed, and position the client appropriately to enhance blood flow.

• Increase the rate of the IV infusion as prescribed.
• Monitor blood pressure and other vital signs closely.
• Administer oxygen if the client shows signs of hypoxia or decreased oxygen saturation.
• Position the client on her left side to prevent aortocaval compression by the gravid uterus.
• Notify the healthcare provider if the hypotension persists or worsens.

 

✘Incorrect answer options:

Position her in the Trendelenburg position. Although the Trendelenburg position (head down, feet up) may temporarily increase venous return, it is not recommended in pregnant women because it can increase the risk of aspiration and does not address the underlying issue of fluid deficit due to vasodilation.

Reduce the rate of the IV infusion. Reducing the IV infusion rate would further decrease the intravascular volume, exacerbating hypotension rather than alleviating it. This option is counterproductive in managing hypotension caused by epidural anesthesia.

Administer oxygen via nasal cannula. While administering oxygen can help improve oxygenation and is often a part of the management for hypotension, it does not directly address the underlying cause of the hypotension, which is decreased intravascular volume. Therefore, it should be considered as a supplementary measure rather than the primary intervention.

 

References

• Lehne, R. A. (2019). Pharmacology for Nursing Care. Elsevier.
• Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2017). Maternal Child Nursing Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Respiratory depression. Magnesium sulfate is often administered intravenously in clinical settings for various indications, including the prevention of seizures in preeclampsia and the management of certain arrhythmias. One of the critical side effects of magnesium sulfate therapy is respiratory depression. This occurs because magnesium sulfate acts as a central nervous system depressant and can interfere with neuromuscular transmission, leading to decreased respiratory effort.

Magnesium acts as a calcium antagonist at the neuromuscular junction, reducing the release of acetylcholine and leading to muscle relaxation. At higher doses, this can significantly depress the respiratory centers in the brainstem, resulting in hypoventilation and respiratory depression. Close monitoring of respiratory rate, depth, and overall respiratory function is crucial in patients receiving magnesium sulfate to prevent severe respiratory compromise.

Think of the body's nervous system as an orchestra, with different sections (muscles, organs) playing their parts according to the conductor's (nervous system's) signals. Magnesium sulfate can act like a heavy blanket thrown over the conductor, muffling their instructions and leading to a slower, quieter performance (reduced muscle activity, including breathing muscles).

Nurses should frequently assess the patient's respiratory status, including rate, depth, and effort. Continuous pulse oximetry may be employed to monitor oxygen saturation levels. It is also important to monitor other signs of magnesium toxicity, such as hypotension, decreased deep tendon reflexes, and altered mental status.

• Ensure continuous monitoring of respiratory rate and oxygen saturation.
• Assess deep tendon reflexes regularly to detect early signs of magnesium toxicity.
• Monitor the patient's blood pressure and level of consciousness.
• Keep calcium gluconate readily available as an antidote for magnesium toxicity.
• Educate the patient about the need for close monitoring and the potential side effects of therapy.

 

✘Incorrect answer options:

Increased blood pressure. Magnesium sulfate typically causes vasodilation and relaxation of smooth muscles, leading to decreased blood pressure rather than an increase. Therefore, this is not an expected side effect.

Hyperreflexia. Hyperreflexia is an exaggerated reflex response, which is not a side effect of magnesium sulfate therapy. In fact, magnesium sulfate can cause hyporeflexia, which is a diminished reflex response, due to its muscle relaxant properties.

Tachycardia. Magnesium sulfate usually does not cause tachycardia. Instead, it can lead to bradycardia (slowed heart rate) as a result of its overall depressant effects on the cardiovascular system.

 

References

• McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Noticeable jitteriness. Noticeable jitteriness in a newborn, especially one born to a diabetic mother, is a concerning sign that requires immediate nursing intervention. Jitteriness can be a symptom of hypoglycemia, which is a common complication in newborns of diabetic mothers. Hypoglycemia occurs because these infants are often exposed to high levels of glucose in utero, which stimulates their pancreas to produce more insulin. After birth, when the glucose supply from the mother is cut off, their insulin levels may remain high, leading to a rapid drop in blood sugar levels.

Hypoglycemia in newborns can cause neurological damage if not promptly addressed. The brain relies on glucose as its primary energy source, and a significant drop in blood sugar can result in seizures, brain injury, and long-term developmental issues.

Imagine a car running out of fuel; it starts to sputter and shake because it doesn't have the energy it needs to run smoothly. Similarly, a newborn's body starts to show signs like jitteriness when it runs low on glucose.

Nurse Sarah should immediately check the newborn’s blood glucose level and initiate appropriate interventions to normalize it. This may include feeding the infant formula or breast milk, administering glucose gel, or in severe cases, starting an intravenous glucose infusion. Continuous monitoring of the blood glucose levels will be necessary to ensure stability.

• Check the newborn's blood glucose level immediately.
• Feed the infant promptly if the blood glucose level is low.
• Administer glucose gel or intravenous glucose if necessary.
• Monitor the newborn's blood glucose levels frequently.
• Educate the parents about signs of hypoglycemia and the importance of regular feeding.

 

✘Incorrect answer options:

Persistent crying. While persistent crying can be a sign of distress or discomfort, it is not as immediately critical as jitteriness in the context of a newborn of a diabetic mother. Persistent crying can be due to various less urgent causes such as hunger, need for a diaper change, or general discomfort.

Increased wakefulness. Increased wakefulness in a newborn is not typically associated with immediate danger. It could be due to a variety of non-critical reasons such as overstimulation, hunger, or a normal variation in the newborn's behavior.

Frequent yawning. Frequent yawning is usually not a sign of a critical issue and can often be attributed to tiredness or the newborn adjusting to life outside the womb. It does not indicate an immediate need for intervention.

 

References

• Murray, S. S., & McKinney, E. S. (2018). Foundations of Maternal-Newborn and Women's Health Nursing. Elsevier.
• Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Alden, K. R. (2016). Maternity and Women's Health Care. Elsevier.

EXPLANATION

 

✔Correct answer:

The infant has a high risk for respiratory distress syndrome. The L/S ratio (lecithin/sphingomyelin ratio) and the presence of phosphatidylglycerol are indicators used to assess fetal lung maturity. An L/S ratio of 2:1 or higher generally indicates mature fetal lungs, which significantly reduces the risk of respiratory distress syndrome (RDS) in the newborn. In this case, the L/S ratio is 1:1, suggesting that the fetal lungs are not yet fully mature. Although phosphatidylglycerol is present, which is a positive sign of lung maturity, the low L/S ratio indicates that the infant is still at a high risk for RDS.

Respiratory distress syndrome occurs due to insufficient production of surfactant, a substance that helps keep the airways (alveoli) in the lungs open. Without adequate surfactant, the lungs are prone to collapse, making it difficult for the newborn to breathe.

Think of surfactant as the oil that keeps a door hinge moving smoothly. Without enough oil, the door (lungs) struggles to open and close properly, making it hard to function (breathe).

Nurse Lily should prepare for the possibility of respiratory support for the infant after birth. This may include ensuring that neonatal resuscitation equipment is ready and that there is a plan for administering surfactant therapy if needed. Additionally, Nurse Lily should continue to monitor Maria's condition and support her through the remainder of her pregnancy.

• Monitor fetal well-being through non-stress tests and biophysical profiles.
• Educate Maria about the signs of preterm labor and the importance of immediately reporting any symptoms.
• Prepare for potential early delivery and coordinate with the neonatal intensive care unit (NICU) team.
• Consider the administration of corticosteroids to accelerate fetal lung maturity if preterm birth is anticipated.

 

✘Incorrect answer options:

The infant has a low risk for congenital anomalies. The L/S ratio and phosphatidylglycerol presence are not indicators of congenital anomalies. These tests specifically assess lung maturity, not structural or genetic anomalies.

The infant has a high risk for intrauterine growth retardation. Intrauterine growth retardation (IUGR) is typically diagnosed through ultrasound measurements of the fetus's size and growth patterns, not through the L/S ratio or phosphatidylglycerol levels.

The infant has a high risk for birth trauma. Birth trauma risk is more associated with factors like fetal size, position, and the delivery method, rather than lung maturity indicators such as the L/S ratio and phosphatidylglycerol presence.

 

References

• Murray, S. S., & McKinney, E. S. (2018). Foundations of Maternal-Newborn and Women's Health Nursing. Elsevier.
• Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Alden, K. R. (2016). Maternity and Women's Health Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Administer Brethine 10 mcg IV. Brethine (terbutaline) is a beta-adrenergic agonist used to manage preterm labor by relaxing uterine muscles and preventing contractions. However, terbutaline is contraindicated or should be used with caution in clients with diabetes because it can increase blood glucose levels and cause hyperglycemia. Given that Emily is a primigravida with diabetes, administering terbutaline could exacerbate her condition and complicate glucose management.

Terbutaline stimulates beta-2 adrenergic receptors, which leads to relaxation of uterine smooth muscle but also results in side effects such as tachycardia and increased blood glucose levels. For a client with diabetes, maintaining stable blood glucose levels is critical, and the use of terbutaline poses a risk for significant hyperglycemia, which can adversely affect both the mother and fetus.

Think of managing diabetes like keeping a car’s speed steady on a highway. Administering terbutaline is like suddenly pressing the accelerator, causing the car to speed up uncontrollably (blood glucose levels to rise), which can be dangerous.

Nurse Jessica should question the order for Brethine due to the potential risks associated with its use in diabetic clients. She should also ensure alternative methods of managing preterm labor are considered, and closely monitor the client’s blood glucose levels.

• Discuss with the healthcare provider the potential risks of terbutaline in diabetic clients and suggest alternative treatments for managing preterm labor.
• Monitor the client's blood glucose levels closely and adjust insulin or other antidiabetic medications as necessary if terbutaline is used.
• Educate the client about the potential side effects of terbutaline and the importance of monitoring blood glucose levels.
• Ensure continuous fetal monitoring to assess the well-being of the fetus during any medication administration.
• Provide supportive care and reassurance to the client regarding the management plan for preterm labor and diabetes.

 

✘Incorrect answer options:

Administer magnesium sulfate 4g (25%) IV. Magnesium sulfate is commonly used in preterm labor to provide neuroprotection to the fetus and to manage preeclampsia. Although it requires careful monitoring, it is not contraindicated in clients with diabetes.

Administer Stadol 1 mg IV push every 4 hours as needed for pain. Stadol (butorphanol) is an analgesic used for pain management during labor. While it should be used cautiously and monitored for respiratory depression, it does not have a significant impact on blood glucose levels and is not contraindicated for clients with diabetes.

Administer Ancef 2g IVPB every 6 hours. Ancef (cefazolin) is a cephalosporin antibiotic often used for prophylaxis in labor and delivery to prevent infection. It does not affect blood glucose levels and is appropriate for use in clients with diabetes.

 

References

• American College of Obstetricians and Gynecologists. (2020). ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 135(5), e110-e127.
• Gabbe, S. G., Niebyl, J. R., Simpson, J. L., & Landon, M. B. (2017). Obstetrics: Normal and Problem Pregnancies. Elsevier.

EXPLANATION

 

✔Correct answer:

The nurse places her thumb on the tendon in the antecubital space and taps her thumb briskly with the reflex hammer. To elicit the biceps reflex, Nurse Karen should place her thumb on the biceps tendon in the antecubital space (the front of the elbow). She then taps her thumb briskly with the reflex hammer. This technique is used to evaluate the C5 and C6 spinal nerves and assess the integrity of the biceps tendon reflex.

The biceps reflex is a deep tendon reflex that tests the function of the musculocutaneous nerve and the spinal cord segments C5 and C6. When the biceps tendon is tapped, it should cause a contraction of the biceps muscle and flexion of the elbow. This reflex helps assess the neuromuscular health and any potential abnormalities in nerve conduction.

Think of the reflex hammer as a doorbell and the biceps tendon as the button. When you press the button (tap the tendon), it sends a signal that rings the bell (causes the biceps to contract). If the bell doesn't ring, something might be wrong with the wiring (nerve pathway).

Nurse Karen should ensure she is using the correct technique to accurately assess the client's reflexes, which is crucial in clients with preeclampsia as hyperreflexia can be an indicator of worsening condition or imminent eclampsia.

• Place the client’s arm so that it is relaxed and supported, typically resting on the nurse's forearm or a flat surface.
• Locate the biceps tendon in the antecubital fossa (inner elbow area).
• Place the nurse’s thumb on the biceps tendon to stabilize it.
• Use the reflex hammer to tap briskly on the nurse’s thumb to elicit the reflex.
• Observe for a reflex contraction of the biceps muscle and flexion of the forearm.
• Document the reflex response accurately and report any abnormal findings to the healthcare provider.

 

✘Incorrect answer options:

The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow. This technique is not used for the biceps reflex; it more closely resembles the technique for testing the triceps reflex, which involves tapping the triceps tendon just above the elbow.

The nurse instructs the client to let her legs dangle while striking the area below the patella with the blunt side of the reflex hammer. This describes the technique for eliciting the patellar reflex, not the biceps reflex. The patellar reflex tests the L2, L3, and L4 spinal segments.

The nurse instructs the client to rest her arms loosely at her side while striking the tendon just above the wrist. This technique describes the method for eliciting the brachioradialis reflex, which tests the C5 and C6 spinal segments but is not the correct method for the biceps reflex.

 

References

• Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking. Wolters Kluwer.
• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mosby's Guide to Physical Examination. Elsevier.

EXPLANATION

 

✔Correct answer:

Increased hepatic enzyme levels. HELLP syndrome is a severe form of preeclampsia that stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. Increased hepatic enzyme levels indicate liver dysfunction, which is a key component of HELLP syndrome. This condition is life-threatening and requires prompt diagnosis and management.

HELLP syndrome involves three major abnormalities:

• Hemolysis (H): Destruction of red blood cells, leading to anemia.
• Elevated Liver enzymes (EL): Indicating liver damage or dysfunction.
• Low Platelet count (LP): Resulting in thrombocytopenia and increased risk of bleeding.

These abnormalities arise due to the endothelial damage and microvascular injury associated with preeclampsia, leading to a cascade of systemic inflammation and coagulation disorders.

Think of the liver enzymes as smoke signals. Just like smoke signals can indicate a fire somewhere, elevated liver enzymes indicate something wrong in the liver, in this case, due to the systemic effects of HELLP syndrome.

Nurse Tina should monitor Sara’s vital signs and symptoms closely, and prepare for potential interventions such as blood transfusions, medication to control blood pressure, and delivery of the baby if indicated.

• Monitor vital signs, particularly blood pressure, and signs of worsening preeclampsia.
• Prepare for laboratory tests to measure liver enzymes (ALT, AST), platelet count, and signs of hemolysis (e.g., LDH levels).
• Ensure close fetal monitoring to assess the baby’s well-being.
• Provide education to Sara and her family about the condition and the importance of monitoring and potential treatments.
• Support the patient emotionally, considering the high-risk nature of her condition and potential interventions, including early delivery.

 

✘Incorrect answer options:

Increased blood glucose levels. Increased blood glucose levels are not a diagnostic criterion for HELLP syndrome. They are more indicative of conditions such as diabetes mellitus.

Increased platelet count. HELLP syndrome is characterized by low platelet count (thrombocytopenia), not an increased platelet count. A low platelet count is a critical component in the diagnosis of HELLP syndrome.

Increased creatinine clearance. Increased creatinine clearance is not associated with HELLP syndrome. In fact, renal dysfunction in HELLP syndrome would more likely present as decreased creatinine clearance, reflecting impaired kidney function.

 

References

• American College of Obstetricians and Gynecologists. (2020). ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology, 135(6), e237-e260.
• Sibai, B. M. (2004). Diagnosis and management of gestational hypertension and preeclampsia. Obstetrics & Gynecology, 102(1), 181-192.

EXPLANATION

 

✔Correct answer:

The Fluorescent Treponemal Antibody (FTA) test. The Fluorescent Treponemal Antibody (FTA) test is considered the best option for diagnosing Treponema pallidum, the bacterium responsible for syphilis. The FTA test is a treponemal test that specifically detects antibodies against T. pallidum, providing a highly specific diagnosis.

Treponema pallidum is the causative agent of syphilis, a sexually transmitted infection. Upon infection, the body produces specific antibodies against the bacterium. The FTA test uses fluorescent-labeled antibodies to detect these specific antibodies in the patient's blood, indicating a syphilis infection. This test is highly specific and can confirm a diagnosis after initial screening tests.

Think of the FTA test as a detective with a unique flashlight that can highlight specific fingerprints (antibodies) left behind by a particular suspect (T. pallidum), providing clear evidence of their presence.

When syphilis is suspected, it is important to use a specific and reliable test for diagnosis. Nurse Sam should ensure that the appropriate diagnostic tests are ordered and follow up on the results to guide further treatment.

• Ensure the patient undergoes the FTA test for a specific and accurate diagnosis of syphilis.
• Educate the patient about the testing process and the importance of accurate diagnosis for effective treatment.
• Discuss follow-up steps based on the test results, including treatment options if syphilis is confirmed.
• Emphasize the importance of notifying sexual partners and practicing safe sex to prevent the spread of the infection.
• Provide resources and support for managing and treating syphilis, including counseling services if needed.

 

✘Incorrect answer options:

The Venereal Disease Research Laboratory (VDRL) test. The VDRL test is a non-treponemal test that screens for syphilis by detecting non-specific antibodies. While useful for initial screening, it is less specific and can produce false-positive results. Confirmatory testing with a treponemal test like the FTA is necessary.

The Rapid Plasma Reagin (RPR) test. Similar to the VDRL test, the RPR test is a non-treponemal screening test that detects non-specific antibodies. It is useful for initial screening but also requires confirmation with a more specific treponemal test, such as the FTA test.

The Thayer-Martin Culture (TMC) test. The Thayer-Martin Culture test is used to isolate and identify Neisseria gonorrhoeae, the bacterium responsible for gonorrhea, not Treponema pallidum. It is not appropriate for diagnosing syphilis.

 

References

• Centers for Disease Control and Prevention (CDC). (2021). Syphilis - CDC Fact Sheet. Retrieved from https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm
• Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommendations and Reports, 64(RR-03), 1-137.

EXPLANATION

 

✔Correct answer:

Herpes. The description of a small, painful blister on the vulva is most indicative of a herpes simplex virus (HSV) infection. HSV is characterized by the appearance of painful blisters or ulcers in the genital area. These blisters can break open, leading to ulceration and further discomfort.

Herpes simplex virus is a common sexually transmitted infection caused by HSV-1 or HSV-2. The virus can lie dormant in nerve cells and reactivate periodically, causing outbreaks of blisters and sores. The initial infection may present with multiple painful blisters, while recurrent outbreaks may be less severe but still painful.

Imagine HSV as a sleeping dragon that occasionally wakes up and breathes fire (painful blisters) in the same area. The dragon goes back to sleep (virus becomes dormant), but the area remains sensitive and can flare up again.

Nurse Amy should prioritize managing the symptoms and preventing transmission. This involves educating Laura about the nature of HSV, ways to alleviate discomfort during outbreaks, and measures to reduce the risk of transmission to sexual partners.

• Refer the client to the physician for evaluation and prescription of antiviral medications (e.g., acyclovir, valacyclovir) to reduce the severity and frequency of outbreaks.
• Educate Laura on keeping the affected area clean and dry to promote healing and prevent secondary infections.
• Discuss the importance of avoiding sexual contact during outbreaks and the consistent use of condoms to reduce transmission risk.
• Provide emotional support and resources for counseling if needed, as an HSV diagnosis can be distressing.
• Encourage Laura to inform her sexual partners so they can be aware and take precautions.

 

✘Incorrect answer options:

Syphilis. Syphilis typically presents with a single, painless chancre during its primary stage. These chancres are firm and round, unlike the painful blisters associated with herpes.

Gonorrhea. Gonorrhea is usually asymptomatic or may present with symptoms such as vaginal discharge, dysuria, and pelvic pain. It does not typically cause painful blisters.

Condylomata. Condylomata, also known as genital warts, are caused by certain strains of HPV. They appear as painless, flesh-colored growths rather than painful blisters.

 

References

• Centers for Disease Control and Prevention (CDC). (2021). Genital Herpes - CDC Fact Sheet. Retrieved from https://www.cdc.gov/std/herpes/stdfact-herpes.htm
• Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommendations and Reports, 64(RR-03), 1-137.

EXPLANATION

 

✔Correct answer:

Cervical cancer. Human papillomavirus (HPV) is a significant risk factor for the development of cervical cancer. Certain strains of HPV, particularly HPV-16 and HPV-18, are strongly associated with the majority of cervical cancer cases. These high-risk types of HPV can cause changes in the cervical cells, leading to dysplasia and eventually to malignancy if not detected and treated early.

HPV infection can lead to the development of cervical cancer through a process of persistent infection with high-risk HPV types, which cause cellular changes in the cervical epithelium. The viral DNA integrates into the host cell DNA, leading to the expression of viral oncogenes (E6 and E7), which interfere with the tumor suppressor proteins (p53 and Rb). This results in uncontrolled cell division and potential progression to cervical intraepithelial neoplasia (CIN) and, ultimately, invasive cervical cancer.

Think of HPV as a tiny vandal that sneaks into a house (the cervical cells). If it stays for a long time and isn't caught, it can cause significant damage to the structure of the house, leading to serious issues (cervical cancer). Regular inspections (Pap smears and HPV testing) can help catch the vandal early and prevent the damage.

Nurse Lisa should provide education on the importance of regular Pap smears and HPV testing to detect any early changes in the cervical cells. She should also discuss the availability of the HPV vaccine, which can protect against the most common high-risk strains of HPV, and emphasize the need for follow-up care and monitoring.

• Educate Maria about the link between HPV and cervical cancer, emphasizing the importance of regular screening.
• Discuss the HPV vaccine as a preventive measure, especially for younger populations who have not yet been exposed to the virus.
• Encourage safe sexual practices to reduce the risk of HPV transmission.
• Provide resources for support and further information about HPV and cervical cancer.
• Advise on lifestyle modifications that can support overall cervical health, such as smoking cessation and a healthy diet.

 

✘Incorrect answer options:

Hodgkin’s lymphoma. Hodgkin's lymphoma is a type of cancer that affects the lymphatic system and is not associated with HPV infection. Its risk factors are largely unrelated to HPV.

Multiple myeloma. Multiple myeloma is a cancer of plasma cells in the bone marrow and has no known connection to HPV infection. Its etiology involves different risk factors, such as genetic predispositions and certain chemical exposures.

Ovarian cancer. Ovarian cancer is not associated with HPV infection. The risk factors for ovarian cancer include age, family history, and certain genetic mutations like BRCA1 and BRCA2, but HPV is not a contributing factor.

 

References

• Centers for Disease Control and Prevention (CDC). (2020). Human Papillomavirus (HPV) and Cancer. Retrieved from https://www.cdc.gov/cancer/hpv/
• American Cancer Society. (2019). Cervical Cancer Risk Factors. Retrieved from https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html

EXPLANATION

 

✔Correct answer:

Inform the attending physician immediately. Observing a papular lesion on a laboring client's perineum is a significant finding that requires prompt attention. Such lesions could indicate a potential infection, such as herpes simplex virus (HSV), which poses risks to both the mother and the newborn. Immediate notification of the attending physician is crucial to ensure proper assessment and timely intervention, potentially altering the delivery plan to reduce the risk of neonatal transmission.

Papular lesions on the perineum during labor can be indicative of an active infection. In the case of HSV, the virus can be transmitted to the newborn during vaginal delivery, leading to neonatal herpes, which can cause severe complications such as neurological damage or death. Therefore, recognizing and addressing this promptly is essential for the safety of both the mother and the infant.

Imagine you are preparing a meal, and you notice a potential source of contamination, like a spot of mold on the cutting board. The first step would be to address it immediately to prevent any harm from consuming contaminated food. Similarly, addressing a suspicious lesion immediately in a laboring client helps prevent potential harm to the newborn.

Upon observing a papular lesion, Nurse Kelly should take immediate steps to inform the attending physician. This allows for appropriate diagnostic tests to be performed and the consideration of alternative delivery methods, such as a cesarean section, to prevent vertical transmission of infections like HSV.

• Notify the attending physician of the observation without delay.
• Prepare to assist with further diagnostic evaluation as ordered by the physician, such as a viral culture or PCR test.
• Provide emotional support to the client, explaining the importance of the observation and the steps being taken to ensure safety.
• Follow infection control protocols to prevent any potential spread of infection within the unit.
• Document the observation and actions taken in the client’s medical records.

 

✘Incorrect answer options:

Record the observation in the medical records. While documentation is important, the immediate priority is to inform the physician. Simply recording the observation without taking further action delays critical intervention.

Get the client ready for a cesarean section. Preparing for a cesarean section is a potential step after the physician evaluates the lesion and determines the need for surgical intervention. However, Nurse Kelly's initial action should be to inform the physician, not to assume or initiate a cesarean section without further orders.

Proceed with the standard care plan. Proceeding with the standard care plan ignores the significant finding and risks compromising the safety of the mother and newborn. Immediate action and deviation from the standard plan are warranted in this scenario to address the potential infection.

 

References

• Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Alden, K. R. (2016). Maternity and Women's Health Care. Elsevier.
• Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Lippincott Williams & Wilkins.