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Thursday, September 11, 2008

Nclex Med Surg: Nclex Study Course

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The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. Dilantin are given to clients with history of seizure disorder.

The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may be noncompliant with the medication regimen. If the level is within the therapeutic range, the client is most likely compliant with medication therapy. Drug is given to COPD patients.

The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0 is within therapeutic range, and the nurse would administer the next dose as scheduled.

An International normalize ratio (INR) of 2.0 to 3.0 is appropriate for most clients. An INR of 3.0 to 4.5 is recommended for clients with mechanical heart valves. If the INR is below the recommended range, the warfarin sodium dose would be increased. If the INR is above the recommended range, the warfarin sodium dose would be decreased. Since the value identified in this question is within the therapeutic range, the nurse would administer the next dose of warfarin.

An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one’s body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual’s private affairs are unreasonably intruded. In this situation, the nurse can be charged with battery because the nurse administers a medication that the client has refused.

Defamation takes place when something untrue is said (slander) or written (libel) about a person, resulting in injury to that person’s good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the physician may be aware of the biopsy results, the physician decides when it is best to share such a diagnosis with the client.

If the physician writes an order that requires clarification, it is the nurse’s responsibility to contact the physician for clarification. If there is no resolution regarding the order because the order remains as it was written, after the physician has been contacted or because the physician cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until clarification is obtained.

Nurses need their own liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

A Good Samaritan Law is passed by a state legislature to encourage nurses and other health care providers to give care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called “immunity from suit,” this protection usually applies only if all of the conditions of the law are met, such as the heath care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The other steps are: activate the alarm, contain the fire, then evacuate as needed. This is a universal standard that can be applied to any type of fire emergency. The nurse first removes the victim from the area. Pulling the nearest fire alarm would be the next step. The nurse next contains the fire and then extinguishes the fire.

Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent.

The client with hyperphosphatemia should avoid foods that are naturally high in phosphates. These include fish, eggs, milk products, vegetables, whole grains, and carbonated beverages. Coffee, tea, and cocoa are not high in phosphates.

The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition, the nursing staff needs assignments so that they can begin client assessments and begin delivering client care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure that needed equipment is available in the event of an emergency. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next begin the problem-solving process related to finding a charge nurse for the next shift. Since this activity directly affects client care, this would be done before reading the stack of mail.

Arriving late to work is an unacceptable behavior. Although the nurse’s behavior has caused unrest with other staff members, the primary concern is that this behavior affects client care. The nurse manager needs to confront the nurse, discuss the lateness, and initiate problem-solving measures that ensure that the behavior does not continue.

The nurse needs to stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to contact the supervisor to obtain an additional staff member to care for the client. Since the client has a head injury, a major concern is the development of increased intracranial pressure (ICP). The application of restraints may agitate the client, causing further restlessness and thus increasing ICP. A nursing assistant is not trained to monitor for increased ICP. It is inappropriate to ask a family member to sit with the client.

If a conflict arises, it is most appropriate to try to resolve the conflict directly. In this situation, the nurse has attempted to explain the reasons for being uncomfortable with the surgeon but was unable to resolve the conflict. The nurse would then most appropriately use the organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the surgeon or seek assistance from the nursing supervisor.

External disasters occur in the community, and many victims may be brought to the emergency room for care. In this situation, the nurse manager would initially contact the nursing supervisor about the need for additional staffing and to discuss activation of the disaster plan. The nurse manager should ask, not demand that nurses from the night shift stay until all of the victims are treated. The nurse manager would not ask emergency medical services to take the victims to another hospital or close the emergency room temporarily to incoming clients. These decisions are made by administration.

If a nurse feels that an assignment is more difficult than the assignment delegated to other nurses on the unit, the nurse would most appropriately discuss the assignment with the nurse manager of the neurological unit. The nurse may or may not have a more difficult assignment than the other nursing staff. However, this action will assist in either identifying the rationale for the assignment or determining if the assignment is actually more difficult. A nurse would not refuse an assignment. Specific situations may be present in which a nurse should not take care of a specific client, for example, if a pregnant nurse is assigned to care for a client with rubella or a client with an internal radiation implant. In these situations, the nurse would also discuss the assignment with the nurse manager. The nurse would not return to the cardiac unit; this would be client abandonment, and this action does not address the conflict directly.

The signs of hypoglycemia and hyperglycemia can be difficult to distinguish. Weakness, headache, and blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in confirming the diagnosis so that the appropriate action can be taken.

Hypoglycemia is immediately treated with 10 to 15 grams of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include 1/2 cup of fruit juice, 1/2 cup of regular (nondiet) soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes or 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup.

Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps to alleviate pain. Ice is contraindicated, because it may add more damage to already injured skin.

When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain can be alleviated by applying an ice pack and elevating the site.

When a Salem sump tube is connected to suction, the air vent permits a free, continuous flow of secretions. The air vent should never be clamped or tied off, connected to suction, or used for irrigation. The nurse manager should handle this problem directly with the nurse who is performing this action and should initially review the skills checklist of the nurse who is tying the knots to assess if this skill has ever been performed and validated.

When cord compression is suspected, the woman is immediately repositioned. The client’s hips can be elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hands-and-knees position can reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves.

If a nonreassuring fetal heart pattern occurs (tachycardia, bradycardia, decreased variability, and late decelerations), the nurse would intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately. The infusion rate of the nonadditive IV solution is increased. The client is positioned in a side-lying position, and oxygen via a snug facemask is administered at 8 to 10 liters per minute. The physician is notified of the adverse reactions, the nursing interventions that have been implemented, and the client’s response to the interventions. The maternal blood pressure is monitored closely.

If physical abuse or neglect is suspected, the priority nursing action is to assess the client, treat any physical injuries, and ensure that the client is safe. The nurse also notifies the physician and the social worker to investigate the situation. All states in the United States and other Western countries have laws requiring health care professionals to report suspected elder abuse. Calling the police is a premature action. Telling the son that he cannot visit with his mother could initiate aggressive behavior in the son. Although the nurse may be involved in obtaining psychiatric assistance for the son, this is not the priority action.

Severe leg pain, once traction has been established, indicates a problem. A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client, and if that is ineffective, then calls the physician. The nurse never removes traction weights unless specifically prescribed by the physician. The client should be medicated only after an attempt has been made to determine and treat the cause.

With a trachea–innominate artery fistula, a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure from the tracheostomy tube causes necrosis and erosion of the innominate artery. This situation is a life-threatening complication. The tracheostomy tube is immediately removed. Direct pressure is then applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.

The nurse should monitor the client’s heart rate and pulse oximetry during suctioning to assess the client’s tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse terminates the suctioning procedure. Using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the catheter should not exceed half the size of the tracheal lumen. In adults, the standard catheter size is 12 to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia.

In most situations, clamping of chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. The physician may need to be notified, but this is not the immediate action. The client would not be instructed to inhale.



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