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Sunday, September 7, 2008

Nclex Tips 18 (Pearson Nclex)

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Antacids are generally not administered with other medications because of their interactive effects. Additionally, antacids delay the absorption of other medications

The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce the intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are considered to be low-calcium foods.

Sodium should not be limited for the client with hypercalcemia unless contraindicated for another reason, such as cardiac disease. When sodium is retained, then calcium is lost through the kidneys.

The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The client with a thoracic burn and smoke inhalation requires aggressive pulmonary measures to prevent atelectasis and pneumonia. These include turning and repositioning, using humidified oxygen, providing incentive spirometry, and suctioning on an as-needed basis. The client should not be left lying in a single position and should not have the head of bed flat. These could promote the development of complications by limiting chest expansion.

Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowler’s position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified and the nurse documents the occurrence and the nursing actions implemented.

Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, polyphagia), or by laboratory values. Diabetes mellitus is diagnosed by an abnormal glucose tolerance test, or when random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater than 140 mg/dL on two separate occasions.

Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon.

The client with hypertension is at risk for cardiovascular complications, such as angina pectoris, myocardial infarction, and heart failure. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart. The client should know to report the onset of chest pain immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy such as levothyroxine sodium.

Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen.

Fludrocortisone acetate (Florinef) is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addison’s disease. Mineralocorticoids cause renal resorption of sodium and chloride ions, and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body.

The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment.

A traumatic open pneumothorax is an emergency. Stopping the flow of air through the opening in the chest wall is a life saving measure. In such an emergency, anything may be used that is large enough to fill the chest wound including a towel, a handkerchief, or the heel of the hand. If conscious, the victim is instructed to inhale and strain against a closed glottis. This action assists in reexpanding the lung and ejecting the air from the thorax. In the hospitalized client who experiences an open pneumothorax, the opening is plugged by sealing it with gauze impregnated with petrolatum.

The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history, and whether or not the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a concern but is not the priority.

Clients with myxedema or hypothyroidism have decreased metabolic demands from reduced metabolic rate. For this reason they often experience weight gain. The diet should be low in calories overall and yet be representative of all food groups.

Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder then is one that is high in calcium but low in phosphorus, because these two electrolytes have inverse proportions in the body.

Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If no external air leak is present, the physician is notified immediately because an air leak may be present in the pleural space. Leaking and trapping of air in the pleural space can result in a tension pneumothorax.

The client taking NPH insulin obtains peak medication effects 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse would teach the client to watch for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger.

Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, since there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures can lead to pain and bruising. The arm should be allowed to hang dependently, and the finger can be milked to promote obtaining a good size blood drop.

Diabetic clients should take in approximately 15 grams of carbohydrate every 1 to 2 hours when unable to tolerate food due to illness.

The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse must plan to monitor the results of serum potassium levels carefully, and report hypokalemia

In the immediate postoperative period following a radical neck dissection, the nurse assesses for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea). This finding is reported immediately, because it indicates airway obstruction.

Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early, so that appropriate action can be taken

In functional nursing, a task approach method is used to provide care to clients.

The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are deep and nonlabored. They occur as the body tries to eliminate carbon dioxide to compensate for lactic acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the client’s respiratory status as part of the client’s overall status.

The client is likely to have tachycardia due to efforts by the body to compensate for the effects of anemia. The client with anemia is likely to complain of fatigue, because of decreased ability of the body to carry oxygen to tissues to meet metabolic demands. Increased respiratory rate is not an associated finding, although some clients may have shortness of breath.

Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression is an oncological emergency, and the physician should be notified.

The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters.

Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole, not chewed. Because the client might experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy.

For most hematological laboratory studies, including CBC, no special care is needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat prior to the laboratory test being drawn.

Before bone marrow aspiration, the site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin, and decreases the risk of infection from the procedure.

When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, a bed bath, ambulate a client with a walker, take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member.

After ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid moving the head rapidly, bouncing, and bending over for 3 weeks.

Exacerbation of Ménière’s disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects.

The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure, since the client is at high risk. Acetaminophen may be given for discomfort, and aspirin should be avoided because it could aggravate bleeding

The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements.

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

The RN would plan to care for the client who is scheduled for surgery at 1:00 p.m. first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, many times the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared.

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