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Monday, November 17, 2008

Nclex 3500 - Nclex Testing

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Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky in color from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal elevated blood urea nitrogen, creatinine, C-reactive protein level, and antistreptolysin O titer.

A bone marrow aspiration will identify aplastic anemia and will show pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes. A Schilling test is diagnostic for pernicious anemia. A sickle cell screen is diagnostic for sickle cell anemia.

The management of dyspnea is generally directed toward alleviating the cause. Symptom relief can be achieved or at least aided by placing the client at rest with the head of the bed elevated. In severe cases, supplemental oxygen is used. Monitoring of oxygen saturation detects early complications but does not help the client. Likewise, placing an oxygen cannula at the bedside for use would not help the client.

A venous stasis ulcer is one that has a dark, reddish base and is surrounded by skin that is brownish and edematous. This occurs because the ulcer is caused by the accumulation of the waste products of metabolism. These waste products are not cleared because of venous congestion. By contrast, arterial ulcers have a pale and deep base and are surrounded by tissue that is pale and cool, with trophic changes (dry friable skin, loss of hair). Arterial ulcers are caused by tissue ischemia from an inadequate arterial supply of oxygen and nutrients.

An arterial ulcer that is clean with granulation tissue should be allowed to heal without disruption of the wound bed. This is best accomplished with a dressing that does not debride the wound, causing disruption of the wound base. This makes wet-to-damp dressings optimal. A wet-to-dry dressing dries on the wound and pulls tissue with it when it is removed. Half strength peroxide and half strength povidone-iodine are examples of solutions that may be used during wound irrigation

The client’s signs and symptoms are compatible with rupture of the aneurysm. Typical signs and symptoms include back and flank pain and ecchymosis of the flank and perianal area, pulsating abdominal mass, lightheadedness, nausea, and signs of shock. The client requires surgical intervention for the treatment of this emergency.

Varicose veins are more common after the age of 30 in clients who have occupations that require prolonged standing. They also occur more frequently in pregnant women, obese persons, and those with a positive family history of systemic problems, such as heart disease. Conservative treatment in these individuals focuses on promoting venous return to the heart.

Ototoxicity and nephrotoxicity are associated with the use of streptomycin. The blood urea nitrogen and creatinine are measured during therapy, as is the urine output. The client taking isoniazid (INH) is at risk for hepatotoxicity, peripheral neuritis, and optic neuritis. Peripheral neuritis and optic neuritis is associated with the use of ethambutol (Myambutol). Jaundice is associated with the use of pyrazinamide.

An area of induration of 15 mm or more is considered positive for clients in low risk groups. An area of induration of more than 5 mm is considered positive for clients in high risk groups, which include those with known or suspected human immunodeficiency virus, intravenous drug users, those who had close contact with TB, or a client with a chest x-ray suggestive of previous TB. An area of induration of more than 10 mm is considered positive for clients in all other low risk groups.

The Allen test is performed before drawing arterial blood gases. The radial and ulnar arteries are occluded in turn and then released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation, and that site may be used.

RA is a systemic disease, and clinical manifestations may occur in various parts of the body. However, the joints are generally affected first. Stiffness occurs after inactivity such as sleep or prolonged sitting. The client will have morning stiffness that lasts for at least 1 hour. RA is a connective tissue disease that most commonly causes inflammation of the joints and subsequent joint deformity.

The client with fractured ribs typically has pain over the fracture site with inspiration and palpation. Respirations are shallow, and guarding of the area is often noted on the part of the client. Bruising may or may not be present.

The client with flail chest experiences respiratory distress. The client has severe dyspnea and cyanosis, accompanied by paradoxical chest movement. The flail segment no longer has bony or cartilaginous connections with the rest of the rib cage. Lacking attachment to the thoracic skeleton, the flail section “floats,” moving independently of the chest wall during ventilation. This abnormality disrupts the normal bellows action of the thorax, and the flail section and underlying tissue are sucked in with inspiration (instead of expanding outward as normal) and “blown out” with expiration (instead of collapsing normally inward). Respirations are shallow and rapid.

The client who has early signs of respiratory failure will have an increased respiratory rate (12 to 20 is normal) and a Paco2 that is greater than 45 mm Hg (normal is 35 to 45 mm Hg). Other signs of respiratory failure include changes in respiratory pattern and lung sounds, and hypoxemia. Early signs are subtle. As the respiratory failure becomes more and more apparent, these values will become increasingly abnormal

The client’s condition is most improved with increasing oxygen levels and a chest x-ray that shows clearing of prior abnormalities. An arterial oxygen level of 80 to 100 is normal, and the chest x-ray should be clear (or without infiltrates).

A T4 cell count that is less than 200/mm3 and a T4 :T8 ratio of less than 2 indicates that the client is exhibiting immunological manifestations of the disease and is at risk for opportunistic infection. The nurse uses this information in planning prevention control measures for the client.

To assess the median nerve status, the client should be instructed to grasp the nurse’s hand. The nurse should note the strength of the client’s first and second fingers. A weak grip may indicate compromise of the median nerve. Asking the client to move the thumb toward the palm and back to the neutral position is assessing the radial nerve status. Asking the client to spread all fingers wide and resist pressure is assessing the ulnar nerve status. Assessing for flexion of the biceps by asking the client to raise the forearm is assessing for cutaneous nerve status.

Severely anemic persons with hemoglobin well below 8 g/dL appear pale and always feel exhausted. They may have palpitations, sensitivity to cold, loss of appetite, profound weakness, dizziness, and headaches.

Schilling's test measures the absorption of orally administered radioactive vitamin B12 before and after parenteral administration of intrinsic factor. This procedure detects the loss of intrinsic factor and is the discriminative test for pernicious anemia. Red blood cells are usually decreased, the bone marrow may contain high numbers of megaloblasts, and the serum lactate dehydrogenase will be extremely high in pernicious anemia. However, the Schilling's test is the test that will confirm the diagnosis.

Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of congestive heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.

When the neutrophil count is less than 500/mm3 visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants and flowers are removed from the client's room. The client is placed on a low bacteria diet that excludes raw fruits and vegetables.

When the platelet count is less than 20,000/mm3, the client is a risk for bleeding, and the nurse would institute bleeding precautions. Neutropenic precautions would be instituted for a client with a low neutrophil count. Contact isolation is initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route.

Heparin is an anticoagulant that can cause bleeding as an adverse effect. The nurse would monitor the client for abdominal pain or swelling, backache, dizziness, headache, hematemesis, hemoptysis, hematuria, black or bloody stools, and Hematest-positive urine/stool, or nasogastric drainage. Overt signs include ecchymoses, petechiae, hematomas, nosebleeds, and bleeding from gums, wounds, or invasive line insertion sites.

Clients with chronic venous insufficiency are advised to avoid crossing the legs, sitting in chairs where the feet do not touch the floor, and wearing garters or sources of pressure around the legs (such as girdles). The client should wear elastic hose for 6 to 8 weeks, and perhaps for life. Venous problems are characterized by insufficient drainage of blood from the legs returning to the heart. Thus, interventions need to be aimed at promoting flow of blood out of the legs and back to the heart. The client should sleep with the foot of the bed (not the head of the bed) elevated to promote venous return during sleep.

Sodium intake can be increased by the use of several types of products, including toothpaste and mouthwashes; over-the-counter (OTC) medications such as analgesics, antacids, cough remedies, laxatives, and sedatives; and softened water, as well as some mineral waters. Clients are highly advised to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking.

Captopril is an antihypertensive medication (angiotensin-converting enzyme inhibitor). Orthostatic hypotension is a concern for clients taking antihypertensive medications. Clients are advised to avoid standing in one position for lengthy periods of time, to change positions slowly, and to avoid extreme warmth (showers, bath, weather). Clients are also taught to recognize the symptoms of orthostatic hypotension, including dizziness, lightheadedness, weakness, and syncope.

A chest tube drainage system must always be kept level and below the waist of the client (which keeps it lower than the level of the client’s chest). Laying the system on its side would disrupt the water seal and the integrity of the system. Putting it higher than the level of the client’s chest would allow fluid to drain back into the pleural space and is contraindicated.

A three-point gait requires that the client have normal use of one leg and both arms. The client is instructed to simultaneously move both crutches and the affected leg forward, then the unaffected leg should move forward.

To go up the stairs the client should move the unaffected leg up first. The client then moves the affected leg and crutches up. When going down the stairs, the client should move the crutches and the affected leg, then move the unaffected leg down.

A PTT of greater than 100 seconds is prolonged, since the normal is usually 25 to 40 seconds. The client is at risk for bleeding with prolonged times. The nurse should assure that the antidote to heparin, protamine sulfate, is readily available for use if actual bleeding or hemorrhage should occur.

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