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Monday, January 5, 2009

Lippincott's review for NCLEX-RN Rationalized

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Trimming or cutting the cuticles of the nails can lead to injury to the foot by scratching the skin. Even small injuries can be dangerous to the client with diabetes mellitus who has decreased peripheral vascular circulation. A manicure stick can be used to gently push the cuticle back under the nail. Nails can be cut straight across, and after a bath is the best time because the nails are softest. White, cotton stockings are best, and the client needs to inspect the feet daily.

Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from inability of the body to utilize glucose. Dry skin occurs secondary to dehydration related to the polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. Clients should not take extraoral hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of elevated glucose. Therefore, the client must increase fluid intake.

The client is taking famotidine (Pepcid), a histamine receptor antagonist. This implies that the client has a disorder characterized by gastrointestinal (GI) irritation. The only medication of the ones listed in the options that is not irritating to the GI tract is acetaminophen. The other medications could aggravate an already existing GI problem.

Cyclosporine (Sandimmune) is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication, and report them to the physician if experienced. The client is also taught about other side effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints.

After ocular surgery (Glaucoma), the client should wear an eye patch or eyeglasses for protection of the eye. Healing takes place in about 6 weeks. Once the postoperative inflammation subsides, the client’s vision should return to the preoperative level of acuity. Sutures are usually absorbable.

If the client has ascites, sodium and possibly fluids should be restricted in the diet. Total daily calories should range between 2000 and 3000. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The diet should provide ample protein to rebuild tissue but not enough protein to precipitate hepatic encephalopathy.

Clients with multiple myeloma need to be taught to monitor for signs of hypercalcemia and to report them immediately to the physician. Anorexia, nausea, vomiting, polyuria, weakness and fatigue, constipation, and signs of dehydration are signs of moderate hypercalcemia. A fluid intake of 3000 mL daily is required to dilute the calcium overload and prevent protein from precipitating in the renal tubules. Activity is encouraged. Although a high-calorie diet is encouraged, a low-fiber diet can lead to constipation.

The rays of the sun are as damaging to the skin on cloudy, hazy days as they are on sunny days. Sunscreens are recommended and should be applied before exposure to the sun and reapplied frequently and liberally at least every 2 hours. A hat, long-sleeved shirt, and long pants should be worn when out in the sun. Tightly woven materials provide greater protection from the rays of the sun.

Home care instruction for a client receiving a course of chemotheraphy on an outpatient basis includes telling the client may excrete the chemotherapeutic agent for 48 hours or more after administration, depending on the medication administered. Blood, emesis, and excreta may be considered contaminated during this time. The client should not share a bathroom with children or pregnant women during this time. Any contaminated linens or clothing should be washed separately and then washed a second time if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste.

Stomatitis is a term used to describe inflammation and ulceration of the mucosal lining of the mouth. Dietary modifications for this condition include avoiding extremely hot or cold foods, spices, and citrus fruits and juices. The client should be instructed to eat soft foods and take nutritional supplements as prescribed.

The client with breast engorgement should be advised to feed frequently, at least every 2 1/2 hours for 15 to 20 minutes per side. Moist heat should be applied to both breasts for about 20 minutes before a feeding. Between feedings, the mother should wear a supportive bra. During a feeding, it is helpful to gently massage the breast from the outer areas to the nipple to stimulate the letdown and flow of milk.

To provide relief from backache, the nurse would advise the client to use good posture and body mechanics, perform pelvic rock exercises, and to wear flat supportive shoes. The client may also be advised to wear a maternity girdle, avoid overexertion, and sleep in the lateral position on a firm mattress. Back massage is also helpful. Eating small meals would more specifically assist in the relief of dyspnea. Leg elevation assists the client with varicosities.

Spironolactone is a potassium-sparing diuretic, and the client needs to avoid foods high in potassium, such as whole-grain cereals, legumes, meat, bananas, apricots, orange juice, potatoes, and raisins.

Lactulose (Chronulac) retains ammonia in the colon and promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. It should be taken with water or juice to aid in softening the stool. An increased fluid intake and a high-fiber diet will promote defecation. If nausea occurs, the client should be instructed to drink cola or eat unsalted crackers or dry toast. Notifying the physician immediately is not necessary.

Neutrophil counts should range between 3000 to 5800/mm3. A low neutrophil count places the client at risk for infection. When the client is at risk for infection, the client should avoid exposure to individuals with colds or infections. All live plants, flowers, or objects that may harbor bacteria should be removed from the client’s environment. The client should be on a low-bacteria diet and avoid eating any raw fruits and vegetables.

Digoxin is an antidysrhythmic. The most common early manifestations of toxicity are gastrointestinal (GI) disturbances, such as anorexia, nausea, and vomiting. Digoxin blood levels need to be obtained as prescribed to monitor for therapeutic plasma levels (0.5 to 2.0 ng/mL). The client is instructed to take the pulse, hold the medication if the pulse is below 60 beats per minute, and notify the physician. The client is instructed to wear or carry an ID bracelet or card.

With earlier hospital discharge, clients may require support from a home health agency until they are independent in functioning.

Anginal episodes are triggered by events such as eating heavy meals, straining during bowel movements, smoking, overexertion, and experiencing emotional upset, or temperature extremes.

Measures to prevent cystitis include increasing fluid intake to 3 liters per day; eating an acid-ash diet; wiping front to back after urination; taking showers instead of tub baths; drinking water and voiding after intercourse; avoiding bubble baths, feminine hygiene sprays, or perfumed toilet tissue or sanitary pads; and wearing clothes that “breathe” (cotton pants, no tight jeans, no pantyhose under slacks). Other measures include teaching pregnant women to void every 2 hours and teaching menopausal women to use estrogen vaginal creams to restore vaginal pH.

The client with pyelonephritis should take the full course of antibiotic therapy that has been prescribed and return to the physician’s office for follow-up urine cultures if so instructed. The client should learn the signs and symptoms of UTI, and report them immediately if they occur. The client should use all measures that are used to prevent cystitis, which includes consuming fluids to 3 liters per day.

The diet in nephrotic syndrome is limited in sodium. This is done to help control edema, which is a predominant part of the clinical picture. Fluids are not limited unless hyponatremia is present. On the other hand, the client is not encouraged to force fluids. Protein is increased, unless the glomerular filtration rate is impaired. This helps replace protein lost in the urine and ultimately also helps in controlling edema. A part of the clinical picture in nephrotic syndrome is hyperlipidemia, which results from the liver’s synthesis of lipoproteins in response to hypoalbuminemia. Increasing fatty food intake would not be helpful in this circumstance.

Clients with polycystic kidney disease waste sodium rather than retain it, and therefore need an increase in sodium and water in the diet.

Aluminum hydroxide, a common ingredient in antacids, significantly decreases INH absorption. INH should be administered at least 1 hour before aluminum-containing antacids. Food affects the rate of absorption of rifampin (Rifadin), not INH. INH administration with a corticosteroid decreases INH’s effects and increases the corticosteroids effects.

Calcium intake is encouraged to minimize the risk of osteoporosis. The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium may also be added to certain products, such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements are available and recommended for those with typically low calcium intake.

Risk factors for osteoporosis include being female, postmenopausal, of advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and furosemide (Lasix) also increase the risk.

The client is taught to hold the cane on the opposite side of the weakness. This is because, with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.

The client should wear a clean woolen stump sock each day. The stump is cleansed daily with a gentle soap and water, and is dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use. The client should inspect all surfaces of the stump daily for irritation, blisters, or breakdown.

The client who has partial weight-bearing status places 30% to 50% of the body weight on the affected limb. Full weight-bearing status is placing full weight on the limb. Non–weight-bearing status does not allow the client to let the limb touch the floor. Touch-down weight-bearing allows the client to let the limb touch the floor, but not bear weight.

The use of an overhead trapeze is extremely helpful in assisting a client to move about in bed and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility.

Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth, and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued, because it could cause the return of seizures. Fever and sore throat should be reported to the physician (leukopenia).

The client with rheumatoid arthritis should avoid remaining in one position and should change positions or stretch every 20 minutes. To reduce efforts by joints, the client should slide objects rather than lift them. The client should avoid exercises and activities other than gentle range of motion when the joints are inflamed. The client is instructed to avoid stooping, bending, or overreaching.

Older clients with arthritis or shaking hands have difficulty instilling their own eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops.

In a scleral buckling procedure, the sclera is compressed from the outside by Silastic sponges or silicone bands that are sutured in place permanently. In addition, an intraocular injection of air or a gas bubble, or both, may be used to apply pressure on the retina from the inside of the eye to hold the retina in place. If an air or gas bubble has been injected, it may take several weeks to absorb. Vigorous activities and heavy lifting are avoided. An eye shield or glasses should be worn during the day, and a shield should be worn during naps and at night. The client is instructed to clean the eye with warm tap water using a clean washcloth.

Children with cystic fibrosis are managed with a high-calorie, high-protein diet, pancreatic enzyme replacement therapy, fat-soluble vitamin supplements, and if nutritional problems are severe, nighttime gastrostomy feedings or total parental nutrition. Fats are not restricted unless steatorrhea cannot be controlled by increased pancreatic enzymes. Sodium intake is unrelated to this disorder.

Iron should be administered with vitamin C–rich fluids because vitamin C enhances the absorption of the iron preparation. Tomato juice contains a high content of ascorbic acid (vitamin C).

Procainamide (Pronestyl) is an antidysrhythmic that is available in a sustained-release (SR) form. The SR preparations should not be broken, chewed, or crushed. The SR form has a wax matrix that may be noted in the stool, and if this occurs, it is not significant. If a dose is missed, an SR tablet may be taken if remembered within 4 hours (2 hours for regular-acting form); otherwise the dose should be omitted. The client or a family member should be taught to monitor the client’s pulse and report any change in rate or rhythm.

The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and to provide good mechanical flushing of the kidney and tube. The nurse encourages the client to take in at least 2000 mL of fluid per day, which is roughly equivalent to 6 to 8 glasses of water

Cognitive therapy is frequently used with clients who have depression. This type of therapy is based on exploring the client’s subjective experience. It includes examining the client’s thoughts and feelings about situations as well as how these thoughts and feelings contribute to and perpetuate the client’s difficulties and mood.

A variety of exercises that involve moving the shoulder and elbow joints are indicated after thoracotomy. These include shrugging the shoulders and moving them back and forth; moving the arms up and down, forward, and backward; holding the hands crossed in front of the waist and then raising them over the head; and holding the upper arm straight out while moving the lower arm up and down. Exercises that move only the wrist joint are of no use after this surgery.

The client with histoplasmosis is taught to avoid exposure to potential sources of the fungus, which includes bird droppings (especially starlings and blackbirds), floors of chicken houses and bat caves, and mushroom cellars.

The client with pulmonary sarcoidosis needs to have follow-up chest x-rays every 6 months to monitor disease progression. If an exacerbation occurs, treatment is initiated with systemic corticosteroids, but corticosteroids are not a part of long-term ongoing management. Home oxygen and ongoing use of incentive spirometer are not indicated.







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