NUR 282/283 Blackburn #comp 1 #comp 2 #comp 3- Galen College, Exams of Nursing

Download NUR 282/283 Blackburn #comp 1 #comp 2 #comp 3- Galen College and more Exams Nursing in PDF only on Docsity! Highlighted orange=was on comp #1 Highlighted purple= was on comp #2 Highlighted pink= comp #3 Week 1 PACU post-op bowel resection with a new colostomy for history of Crohn’s disease: Entry level nurses should know routine colostomy care/teaching as noted in IGGY book. The first action required when receiving a patient is confirming patient identification. Crohn’s Disease (CD) is a chronic inflammatory disease of the small intestine, colon, or both. Same as Ulcerative Colitis (UC), Crohn’s is a recurrent disease with periods of remissions and exacerbations. What are important assessment points for a patient with Crohn’s disease and what discharge teaching would you provide regarding management of Crohn’s disease? See page 1146-1149 in IGGY 10th edition. Assessment points include monitoring for manifestations of peritonitis, small bowel obstruction, and nutritional/fluid imbalances. These patients are at high risk for malnutrition, dehydration, and hypokalemia. Monitor output and daily weights as a decrease in either could indicate dehydration, which means additional fluids are a priority. Nutritional supplements may be needed in addition to a high-calorie, high-protein, high-vitamin, low-fiber diet. TPN or TEN may be needed for a patient with Crohn’s while hospitalized. 3,000 calories per day is indicated. A low-fiber diet is indicated for patients with Crohn’s as well as other GI diseases such as diverticulitis. Teaching should include to avoid GI stimulants such as alcohol and caffeinated beverages. Vit B12 injections may be needed. Fistulas are common with exacerbations and teaching for wound care is indicated if the patient has this complication. Dr. Blackburn Post-op abdominal surgery patients often have an NG placed for decompression of the stomach. This includes post-op colorectal cancer patients, who may also have a colostomy depending on procedure performed. Entry level nurses should know care of patients with an NG tube. Try this practice question and provide a rationale for your response: A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? 1. Use a 22 gauge needle. 2. Select a site on the client’s abdomen. 3. Use the Z-track technique to displace the skin on the injection site. 4. Observe for bleb formation to confirm proper placement. Answer: 2 1. Not correct. For a subcutaneous injection, use a 25 to 27 gauge needle. 2. CORRECT: For a subcutaneous injection, select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). For a subcutaneous injection, pinch a section of skin or pull the skin taut using the thumb and index finger. When administering enoxaparin do not expel the air bubble in the syringe. It’s nitrous oxide and allows the client to receive all the medication during the injection. 3. Not correct. The Z-track technique for IM injections is used for medications that are irritating to the tissue, which includes pulling the skin and tissue taut. Firmly hold in this position while the needle is inserted and the medication is injected. Iron dextran is a medication administered using the Z-track technique. Some facilities require the Z-track technique for all IM injections. For IM, solution volume is usually 1 to 3 mL. The ventrogluteal site is preferable for IM injections and for injecting volumes exceeding 2 mL. If more than 3 mL is needed for the ordered dose, the medication will need to be given in two separate injections. The deltoid site has a smaller muscle mass and can only accommodate up to 1 mL of fluid. 4. Not correct. Bleb formation confirms injection into the dermis, not into subcutaneous tissue. Intradermal are used for tuberculin (Mantoux) testing or checking for medication or allergy sensitivities. Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine-gauge needle (26 to 27 gauge) in lightly pigmented, thin-skinned, hairless sites (the inner surface of the mid-forearm or scapular area of the back) at a 5° to 15° angle. Insert the needle with the bevel up. A small bleb should appear. Do not massage the site after injection. A Mantoux (TB) test should be read 2-3 days after administration. A positive response indicates the client may have been exposed to the TB bacteria or dormant disease. 10mm or > induration is considered positive for exposure to or infection with TB. An induration of more than 5 mm is ○ Maculopapular skin rash: not a serious complication ○ Bronze baby syndrome is a complication (rare) in some infants with cholestatic jaundice when treated with phototherapy. With exposure to phototherapy lamps, infants develop a dark, gray-brown discoloration of skin, urine, and serum. ● The newborn’s bilirubin should start to decrease within 4 to 6 hr after starting treatment. Dr. Blackburn Topic- Rubella immunization: For rubella, immunization of clients who are pregnant is contraindicated because rubella infection can develop. These clients should avoid crowds and young children. Clients who have low titers prior to pregnancy should receive immunizations before becoming pregnant. For those already pregnant, the rubella vaccination is received postpartum due to the effects on fetus in utero. Clients should avoid pregnancy for 28 days after receiving the vaccine. Topic- Transferring: A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select all that apply and include a rationale for your response(s). 1. Request assistance when repositioning a client. 2. Avoid twisting your spine or bending at the waist. 3. Keep your knees slightly lower than your hips when sitting for long periods of time. 4. Use smooth movements when lifting and moving clients. 5. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. Answer: 1, 2, and 4. 1. CORRECT: To reduce the risk of injury, at least two staff members should reposition clients. Prior to transferring clients, determine whether or not the client can assist with the transfer then seek assistance. 2. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury. 3. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back. 4. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury. 5. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles. Dr. Blackburn DKA/metabolic acidosis and is now experiencing manifestations of fluid overload: Topic- DM teaching: Monitor ABGs in all patients with DKA. As ketones increase, acidosis develops with the pH and bicarb decreasing. You should be able to recognize metabolic acidosis ABGs as well as the other acid/base imbalances and the causes for each one. What are important teaching points for patients with diabetes regarding exercise? See page 1284 in IGGY 10th edition, yellow box noting education for patient and family regarding exercise for DM Type 1. Also see blue box on page 1285, know the teaching points listed. It’s important for these patients to consume a carb snack before exercising to prevent hypoglycemia if it’s been more than 1 hour since they had a meal or if they will be doing high intensity exercise. Also, teach patients with DM to avoid exercise if their glucose is not between 80-250. For patients with DM Type 1, exercise is only recommended with a glucose of at least 100 and negative ketones in urine. See action alert box in IGGY page 1284. Ketones indicate insulin levels are not adequate and exercise could elevate blood glucose levels. It’s also important to avoid exercise during times insulin peaks or within 1 hr of insulin injection. They should keep a simple sugar snack available during exercise in case of hypoglycemia. Also teach patients with diabetes manifestations of hypoglycemia and interventions. Hypoglycemia is when blood glucose falls below 70. See pages 1289 -1291 in IGGY 10th edition. Dr. Blackburn Topic- DKA: Risk factors for DKA (diabetic ketoacidosis) ● Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen ● Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) ● Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) ● Infection is the most common cause ● Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose and decreases the effect of insulin Topic- ABGs: Try this practice question from category NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.45, PaO2 94, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid‑base imbalances? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Include a rationale for your response. Answer: 2 1. Not correct. A client who is experiencing respiratory acidosis will have a decreased pH and an increased PaCO2. Possible causes of respiratory acidosis include anesthesia, pneumonia, COPD, ARDS, PE, and overdose. 2. CORRECT: A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, early onset PE, mechanical ventilation, and fear. 3. Not correct. A client who is experiencing metabolic acidosis will have a decreased pH and a decreased HCO3. Possible causes of metabolic acidosis include DKA, renal failure, dehydration, liver failure 4. Not correct. A client who is experiencing metabolic alkalosis will have an increased pH and an increased HCO3. Possible causes of metabolic alkalosis include antacids, prolonged vomiting, and NG suctioning. 3. Require that all clients who have had previous suicidal ideation, plans, or attempts refill their medication every 2 weeks rather than monthly. 4. Suggest that family and friends of previously suicidal clients know the client’s whereabouts at all times. Answer: 1, 2 Having resources such as a crisis phone line number and a specific prevention plan helps clients know what to do if they begin to feel they want to harm themselves. Trained crisis line employees will offer to send help first thing when the client calls. A No Harm contract is important if a patient has expressed suicidal ideation thoughts. Not all medications are lethal enough that access to a month’s supply should be limited. Further, such a limitation is likely to increase costs, which may increase the client's stress. Constant surveillance is unrealistic and potentially distressing to the client. Dr. Blackburn Topic- schizophrenia: Remember test plan reference is also needed as that is where you get the activity statements and category names. Patients with paranoid schizophrenia may experience alterations in thought (delusions). Assess the client for paranoid delusions, which can increase the risk for violence against others. If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others. When caring for patients with schizophrenia: ● Assess for paranoid delusions, which can increase the risk for violence against others. ● If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others ● Ask the client directly about hallucinations. Do not argue or agree with the client’s view of the situation. ● Appropriate comments by the nurse if the client is hallucinating would be “I don’t hear anything, but you seem to be feeling frightened.” ● Attempt to focus conversations on reality-based subjects. ● Provide prepackaged nutritious food because the client might not trust other food sources. ● Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations. Topic- lumbar puncture: Try this practice question from the NCLEX® Category: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures and provide a rationale for your response(s). A nurse is caring for a client who is post-procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) 1. Use the Glasgow Coma Scale when assessing the client. 2. Assist the client to a supine position. 3. Administer an opioid medication. 4. Encourage the client to increase fluid intake. 5. Instruct the client to perform deep breathing and coughing exercises. Answer: 2, 3, and 4. 1. The Glasgow Coma Scale is used to assess a client’s level of consciousness and is not necessary following a lumbar puncture. 2. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. 3. CORRECT: The nurse should administer an opioid medication for a client’s report of headache pain. 4. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. 5. Coughing can increase ICP, which can result in an increase in the client’s headache. Monitor the puncture site for CSF leak. The “halo” sign, clear or yellowish ring surrounding a spot of blood indicates leakage of CSF and is a priority for follow-up. Dr. Blackburn Topic- Delusions: Clients with paranoid schizophrenia may experience delusions and hallucinations, which distorts reality and makes it difficult for the client to lead a normal life. See table 12.1 on page 195 Chapter 12 in your mental health textbook. The table lists types of delusions including persecutory, referential, grandiose, and control as some of the delusions these clients may experience. ● Control delusions are related to beliefs that another person or force is controlling your thoughts and behaviors. ● Grandiose delusions are when one believes they are powerful and important such as a famous playwright. ● Referential delusions are when one believes there is a personal connection to events that are not related such as songs on radio are sending a personal message. ● Persecutory delusions involve imagining one is singled out for harm such as believing food is poisoned. Topic- endocrine: Try this practice question and provide a rationale for your response: The nurse is administering medications on the endocrine unit. Which of the following prescriptions would require follow-up with the provider? 1. Desmopressin acetate for the client with Diabetes Insipidus. 2. Fludrocortisone for a client with Addisonian crisis. 3. Tolvaptan for a client with Cushing’s disease. (follow up fludrocortisone do not give to these patients) 4. NaCl 3% solution IV for a client with SIADH. #3 needs follow-up. 1 does not need follow-up. Desmopressin is used to treat DI. Drug therapy for DI can lead to fluid overload and water toxicity, close monitoring is needed to detect complications. 2 does not need follow-up. Patients with Addisonian crisis have hypotension due to blood volume depletion. Na is low and K is high. Fludrocortisone is often prescribed for patients with adrenal hypofunction but monitoring BP is a priority for patients due to risk of hypertension as a side effect. 3 requires follow-up. Tolvaptan is used to treat SIADH, not Cushing’s. Ketoconazole, etomidate, mifepristone, and pasireotide are medications prescribed for Cushing's to decrease cortisol levels. 4 does not need follow-up. SIADH results in very low Na levels. IV solutions of 3% NaCl and medications tolvaptan or conivaptan are appropriate for patients with SIADH experiencing hyponatremia. Fluid restriction is also implemented for these patients. 1. CORRECT: The client will need the assistance of a physical therapist to assist with mobility skills and maintain muscle strength. Physical therapy will help the patient maintain function/mobility as PT helps with gross motor skills. 2. INCORRECT: A speech therapist assists a client who has speech and swallowing problems, which are not anticipated for this client. 3. CORRECT: The client will need the assistance of an occupational therapist to learn how to perform activities of daily living. Occupational therapists help clients learn how to use tools that help them maintain independence with ADLs/IADLs. OT helps with fine motor skills. 4. CORRECT: The client will need the assistance of a psychologist to adapt to the psychosocial impact of the injury. In an interprofessional team, psychologists provide comprehensive care by collaborating with other disciplines to meet the behavioral, physical, and psychosocial needs for patient well-being. 5. CORRECT: The client will need the assistance of a vocational counselor to explore options for re-employment. Interdisciplinary conferences are appropriate for patients that require multiple therapies/services and/or those with frequent hospitalizations. Ensure patients discharged home with chronic or progressive diseases that affect mobility have a case manager involved in discharge planning. A case manager will help coordinate interprofessional care and support for the patient and family in the home environment. Dr. Blackburn you are the nurse providing care for a client bipolar disorder experiencing severe mania and has lithium prescribed. Topic- lithium: Lithium controls episodes of acute mania and helps prevent the return of mania or depression. Teaching for patients prescribed lithium: ● Advise clients that effects begin within 7 to 14 days. ● Advise clients to take as prescribed. Lithium must be administered in 2 to 3 doses daily due to a short half. Taking lithium with food will help decrease GI distress. ● Lithium is Pregnancy Risk Category D. This medication is teratogenic, especially during the first trimester. ● Encourage clients to adhere to laboratory appointments needed to monitor lithium effectiveness and adverse effects. Emphasize the high risk of toxicity due to the narrow therapeutic range. Need to monitor CBC, serum electrolytes, renal function tests, and thyroid function tests during lithium therapy. ● Provide nutritional counseling. Stress the importance of adequate fluid and sodium intake. Encourage clients to maintain a diet adequate in sodium, and to drink 2,000 mL to 3,000 mL of water each day from food and beverage sources. Conditions that cause dehydration, such as exercising in hot weather or diarrhea, put client at risk for lithium toxicity and should be avoided. ● Instruct clients to monitor for manifestations of toxicity and when to contact the provider. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating. Topic- pediatrics: You learned about health promotion for adolescents in a previous course. Try this ATI practice question from the NCLEX® Category: Health Promotion and Maintenance, Health Screening and provide a rationale for your response: A nurse is providing anticipatory guidance to the caregiver of a 13-year-old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (Select all that apply.) 1. Body mass index 2. Blood lead level 3. 24-hr dietary recall 4. Weight 5. Scoliosis Answer: 1, 4, 5. 1. CORRECT: Recommend that the adolescent have a body mass index screening annually. 2. Not correct. Blood lead level screenings are recommended for children at the age of 1 and 2 years, and for children between the ages of 3 and 6 years who have not previously been screened. 3. Not correct. A 24-hr dietary recall is not a routine screening for an adolescent. 4. CORRECT: Recommend that the adolescent have a weight screening annually. 5. CORRECT: Recommend that the adolescent have a scoliosis screening annually. Dr. Blackburn Topic- bipolar: When caring for clients with bipolar in manic phase we need to set limits and enforce boundaries. As noted in the mental health book staff continually set limits in a firm, nonthreatening, and neutral manner to prevent escalation of behavior and ensure safe boundaries. Topic- disaster triage: You learned about disaster triage in NUR265. Describe the disaster triage tag system. Green tags are the walking wounded; they are not the priority in a disaster. Non-urgent includes minor injuries where treatment can be delayed over 2 hours such as closed fractures, sprains, strains, abrasions, contusions. The urgent category for disaster triage is a yellow tag and includes major injuries that require treatment. These major injuries include open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours. For urgent category with ER triage this includes patients that need attention quickly but not life-threatening injuries. Severe abdominal pain, displaced or multiple fractures/soft tissue injuries, and pneumonia in older adults would be examples of urgent category patients. Individuals with immediate life-threatening injuries get a red tag, which is the emergent category for disasters. The emergent category is the same for disaster and ED triage. This is the category for those with immediate threat to life: manifestations of stroke, respiratory distress/airway obstruction, shock, chest pain/diaphoresis, active hemorrhage (internal bleeding may present as flank pain), unstable vital signs, and cardiac instability. Clothing may need to be cut away with scissors, if contaminated by hazardous material don’t touch even with gloves. Use tongs/forceps to handle clothing and dispose of in biohazard waste. The black tag, or expectant level, in disasters is for those patients expected to die. Black-tagged patients are those with massive head trauma, extensive full-thickness burns, and high cervical spinal cord injury requiring mechanical ventilation. These patients are not the priority in a disaster. The rationale for this seemingly heartless decision is that limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expenses of many others. Dr. Blackburn Priority pt has second degree burn to the chest and arm with rr greater than 30 Topic- bipolar: Examples of tasks nurses may delegate to LVNs and UAPs (provided the facility’s policy and state’s practice guidelines permit) TO LVNs ● Monitoring findings (LVNs can collect data for input to the RN ’s ongoing assessment/care plan) ● Reinforcing client teaching from a standard care plan created by an RN (LVNs cannot do initial teaching or care planning) ● Performing tracheostomy care ● Suctioning ● Finger stick ● Checking NG tube patency ● Administering enteral feedings ● Inserting a urinary catheter ● Administering routine medication (excluding IV medication in some states) ● Wound care/wound vac/dressings TO UAPs Activities of daily living (ADLs) ● Bathing ● Grooming ● Dressing ● Toileting ● Ambulating (not first time up after procedure or surgery) ● Transferring ● Feeding (not for patients with swallowing precautions/no tube feedings) ● Positioning Routine tasks ● Bed making ● Specimen collection ● Intake and output ● Vital signs (recheck is fine but not first set after procedure or surgery) ● Catheter care Dr. Blackburn Topic- hearing aids: I recommend you know correct teaching for patients with a hearing aid (see chart IGGY 10th edition book page 961) including cleaning instructions and recommendations for volume settings. Teach to use soft brush for cleaning with mild soap/water and avoid excessive wetting. Keep extra batteries on hand. The volume should be set at the lowest setting that allows hearing without feedback. Topic- immunosuppression: Immunosuppression/neutropenia due to bone marrow suppression by cytotoxic medications is the most significant adverse effect of chemotherapy. Clients who have neutropenia might not develop a high fever or have purulent drainage, even when an infection is present. We need to monitor the WBC count. Topic- chemotherapy nutrition: Try this NCLEX practice question from the category of Pharmacological and Parenteral Therapies, Pharmacological Pain Management. Provide a rationale for your response. A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? 1. “Your nausea will lessen with each course of chemotherapy.” 2. “Hot food is better tolerated due to the aroma.” 3. “Try eating several small meals throughout the day.” 4. “Increase your intake of red meat as tolerated.” Answer: 3 1. Nausea usually occurs to the same extent with each session of chemotherapy. 2. Cold foods are better tolerated than warm or hot foods because odors from heated foods can induce nausea. 3. CORRECT: Several small meals a day are usually better tolerated by the client who has nausea. If the client does not have nausea encourage consumption of high‑protein, high‑calorie, nutrient‑dense foods and avoidance of low‑ or empty‑calorie foods. Protein needs are increased for those with cancer. 4. Red meat is not tolerated well by the client undergoing chemotherapy because the taste of meat is frequently altered and unpalatable. Dr. Blackburn Topic- anemia: Epoetin alfa is administered to the client who has anemia. This medication will increase red blood cells, which will increase Hemoglobin levels. Try this practice question and provide a rationale for your response: The nurse is precepting a new nurse that is preparing to administer medications for assigned patients. Which of the following actions by the new nurse would require the preceptor to intervene? 1. Preparing to administer naproxen to a patient with recent onset of hepatic encephalopathy due to cirrhosis. 2. Preparing to administer warfarin to a patient that was admitted with a-fib and is currently receiving IV Heparin 3. Preparing to administer PRBCs over 3 hours for a patient with a low Hgb and primed tubing with normal saline 4. Preparing to administer DDAVP to a patient with Diabetes Insipidus (DI) that is experiencing a large urine output Answer: 1 would need follow-up. Naproxen is not appropriate for patients with hepatic encephalopathy. NSAIDs inhibit prostaglandin synthesis and may potentiate renal vasoconstriction, with a resulting drop in glomerular filtration. This could cause the patient to have a decrease in urine output, which would need to be reported. Know what normal output is so you can recognize abnormal. Page 1158 in IGGY 10th edition notes hepatorenal syndrome (HRS) presents with a sudden decrease in urinary flow for these patients as well as high BUN/Crea/urine osmolarity levels and is often a cause of death for these patients. *question answer was pupil went from 7 to 5 mm* 2 would not need follow-up. Warfarin is usually added on day 1 or 2 of Heparin therapy. Warfarin and Heparin are appropriate treatments for patients with a-fib. Remember patients with a-fib are at risk of clots, monitor for manifestations and report immediately. 3 would not need follow-up. Infusing PRBCs over 3 hours and priming the tubing with NS are appropriate actions. 4 would not need follow-up. Diabetes Insipidus results in large volumes of dilute urine output. Desmopressin acetate (DDAVP) is the preferred drug for treatment of DI, which will decrease the amount of urine output. Also, this patient would need fluids for hydration. Dehydration in these patients can be fatal. Dr. Blackburn you are the nurse providing care for a client with preeclampsia in labor at 38 weeks gestation and is receiving magnesium sulfate IV. ● Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and to prevent hemorrhage. ● Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage. Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage. A decreased uterine tone can be produced by pharmacological agents used in general anesthesia. ● Monitor for shock and hemorrhage. Clinical findings of hemorrhage and shock include hypotension, tachycardia, and pallor. Secure IV access with large bore needle if any of these manifestations develop. ● Encourage voiding to prevent bladder distention. Risks during the postpartum period are hemorrhage, shock, and infection. Oxytocin, a hormone released from the pituitary gland, coordinates and strengthens uterine contractions. Breastfeeding stimulates the release of endogenous oxytocin from the pituitary gland. Exogenous oxytocin can be administered postpartum to improve the quality of the uterine contractions. A firm and contracted uterus prevents excessive bleeding and hemorrhage. Uncomfortable uterine cramping is referred to as afterpains. Dr. Blackburn you are the nurse providing care for a female client with MS relapse who needs foley catheter inserted and is experiencing the anger stage of grief. Topic- foley insertion: I recommend you know correct steps/technique for foley insertion. If you need a review of foley insertion, see the video in Galen library listed below. Access the library from within your Canvas course. This video also includes setting up sterile field, which is fundamental nursing knowledge you need to know. Basic clinical skills: Urethral catheterization. Rodriguez, R. (Director). (2010, Jan 01).[Video/DVD] Cypress: Medcom, Inc., https://www.proquest.com/audio-video-works/basic-clinical-skills-urethral-catheterizati on/docview/2376177256/se-2 Links to an external site. Topic- delegation: Try this practice question and provide a rationale for your response: The RN charge nurse is making client assignments. Which client should the charge nurse assign to the LVN/LPN? 1. The morbidly obese client who is suspected of having acute respiratory distress syndrome 2. The recovering MVA client diagnosed with a hemothorax who needs two units of blood 3. The postoperative client with chest tubes who has jugular vein distention and BP of 96/60 4. The client with dyspnea who is scheduled for a bronchoscopy to R/O lung cancer Answer: 4 1. The client suspected of having ARDS is not stable and should not be assigned to an LPN. A more experienced RN should be assigned to this client. 2. The LPN cannot administer blood; therefore, this client should not be assigned to the LPN. An RN needs to verify, initiate, and monitor during the first 15 minutes of blood transfusion. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. 4. A client scheduled for a bronchoscopy is stable and should be assigned to the LPN. This client is the most stable and least critical. Post bronchoscopy an RN would be appropriate to assign as the client will need assessed for return of gag reflex and complications such as bleeding, infection, or hypoxemia. Dr. Blackburn Topic- MS: MS is a chronic disease and one of the leading causes of neurologic disability in young and middle-age adults. It is characterized by periods of remission and exacerbation (flare). Muscle relaxers are often prescribed to patients with MS. Side effects of these medications include dizziness, drowsiness, hypotension, and nausea. Teach to avoid OTC drugs that could cause complications due to possible undesirable additive effects. Also, provide education about energy conservation and to avoid overexertion, stress, extremes of temperatures, humidity, and people with infections. You previously learned about the stages of grief and therapeutic communication in mental health. What are the five stages of grief cancer patients may experience as noted in the Kübler-Ross model? Include examples. Dr. Blackburn Topic- grief: When caring for patients who are experiencing grief (loss of loved one or terminal diagnosis such as cancer), you should be able to recognize the stage of grief a client is experiencing. Here is a review of the KUBLER ROSS MODEL you previously learned: Denial: The client has difficulty believing in an expected or actual loss/ terminal diagnosis. Clients in denial have thoughts of “not me, can’t be true”, they want to believe nothing is wrong and everything is going to be fine. Denial of diagnosis is common with this stage and the client may want another opinion. Time to adjust is needed. This stage may last minutes to months and be characterized by withdrawal. Anger: The client directs anger toward the self, others, a deity, objects, or the current circumstances. Clients experiencing the anger phase of grief have thoughts of “why me?” They may be focused in any number of directions including the person who inflicted the hurt, at the world for letting it happen, at oneself even though nothing could have been done to stop an event from happening (car accident). Bargaining: The client negotiates for more time or a cure. Clients in the bargaining phase of grief have thoughts of “If I can just make it until …..” or “Yes me, but…”; they want more time or something other than the death (make bargains with God). Depression: The client is overwhelmingly saddened by the inability to change the situation. Clients experiencing the depressions stage of grief have thoughts of “Yes, me”; these clients feel sad and numb but still have anger, or sadness. Acceptance: The client acknowledges what is happening and plans for the future by moving forward. Clients in the acceptance stage of grief are coping effectively and have thoughts of “Yes, me but it’s ok”; plans to move forward are set in place. They accept the reality of the loss; there is less anger, sadness, and mourning in this stage. Clients might not experience these stages in order, and the length of each stage varies from person to person. Dr. Blackburn ---------------------------------------------------------------------------------------------------------------- Week 4 you are the nurse providing care for a client post renal transplant with acute rejection has a central line and is developing sepsis. Pulseless ventricular tachycardia is treated as ventricular fibrillation. Remember it this way: Always defib the v-fib! Vfib rhythm on exam make sure to recongnize it For a similar situation in the community, per CPR guidelines verify unresponsiveness, call for help, then check for breathing and pulse. If no pulse, start compressions. Dr. Blackburn Topic- Kidney rejection: Immediately notify the surgeon if any manifestations of organ rejection appear. IGGY 10th edition page 1407 notes the different types of rejection associated with kidney transplant. Also, make note of the critical rescue box on same page. Notify provider if hypotension or excessive diuresis occurs as this reduces blood flow to the new kidney and threatens graft survival. Topic- torts: Try this practice question and provide a rationale for your response. A nurse witnesses an UAP reprimanding a client for not using the urinal properly. The UAP threatens to put a diaper on the client if the urinal is not used more carefully next time. Which of the following torts is the UAP committing? Include a rationale for your response. 1. Assault 2. Battery 3. False imprisonment 4. Defamation Answer: 1 1. CORRECT: Assault is conduct that makes a person fear they will be harmed. 2. Battery is physical contact without a person’s consent. 3. False imprisonment is restraining a person against their will. It includes the use of physical or chemical restraints and refusing to allow a client to leave a facility. 4. Defamation is false communication or communication with careless disregard for the truth with the intent to injure an individual’s reputation. Libel: Defamation with the written word or photographs (a nurse documents in a client’s health record that a provider is incompetent). Slander: Defamation with the spoken word (a nurse tells a coworker that she believes a client has been unfaithful to the spouse). Dr. Blackburn you are the nurse providing care for client receiving gentamicin intravenously and IV site is red and swollen. Topics- IV: The NCLEX category Pharmacological and Parenteral Therapies has a section titled Parenteral/Intravenous Therapies (page 32 of test plan). Monitor intravenous infusion and maintain site is an activity statement noted for this part of the test plan. Registered nurses have a duty to ensure the infusion rate is correct and monitor the site for clinical indications the IV should be removed and rotated to a different site. Manifestations of phlebitis include redness/erythema, inflammation, and tenderness at IV site. Failure to detect an error with an IV could result in infiltration or extravasation. Monitor the rate and site closely. Intervene if needed to prevent pain, swelling, compartment syndrome or, in extreme cases, an amputation of the affected limb. When caring for a patient that develops IV phlebitis manifestations, what are appropriate nursing actions? Dr. Blackburn Topic- incident report: Entry level nurses need to know proper steps for IV insertion and what to monitor for to detect complications. You may want to review information you previously learned on IV insertion. For any peripheral IV, if the site is red and swollen upon assessment the next action is to remove the IV. Phlebitis/infiltration from the IV require the nurse to document in the medical record as well as complete an incident report. Document objectively a description of the facts and your actions. Do not document in the medical record that an incident report was completed. The incident report is for the risk management department in the organization. Again, only document the facts and nursing actions taken. Do not state in the medical record that you completed an incident report. Make sure to view my video on incident reports in the faculty added content module. (Correct documentation: pt ambulating in hall) Protect the fragile skin of older adults with IV insertion by using a soft cloth between the tourniquet and skin or a blood pressure cuff inflated 10 to 15 cm (4 to 6 in) above the insertion site to compress only venous blood flow. Dr. Blackburn Topic- peak and trough: For patients receiving gentamicin the RN is responsible for ensuring peak and trough levels are obtained at the correct time. Obtain the blood specimen for the peak blood level 30 min after the end of the IV infusion. For the trough level, collect the blood sample just before starting the infusion. Topic- delegation: Try this practice question and provide a rationale for your response: The RN is developing a standardized care plan for postoperative care of a client undergoing cardiac surgery. The RN has an LVN and UAP available for delegation of tasks. Which of the following needs to be performed by the RN? 1. Changing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs. 2. Reinforcing teaching about the need to deep breathe and cough at least every 2 hours while awake. 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes. 4. Assisting the client to ambulate in the hall on the second post-op day. Answer: 3 is correct. Development of the plan of care and initial teaching is the responsibility of the RN. LVNs can collect data for the care plan but the initial development for the patient plan of care is the responsibility of the RN. The RN is responsible for reviewing data collected when developing the plan of care. The LVN can perform wound care and reinforce teaching on the importance of coughing and deep breathing to prevent complications. LVNs cannot do initial teaching but they can reinforce what the RN has taught the patient. Assisting with ambulating a patient is an appropriate task to delegate to the UAP. Remember the first time a patient is ambulated or initial VS after surgery or a procedure requires assessment by the RN. We previously covered delegation specifics. Expect delegation questions on comp exams and on NCLEX. Make sure you have reviewed the legal/ethical presentations posted in my faculty added content module, which covers delegation and other important topics you need to know. 4. Metabolic alkalosis Answer: 4 1. Not correct. Respiratory acidosis is not indicated for this client. 2. Not correct. Respiratory alkalosis is not indicated for this client. 3. Not correct. Metabolic acidosis is not indicated for this client. 4. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis. I recommend you know acid/base disorders and ABGs/causes that will present with each one. Expect comp exams to test your knowledge of ABGs this term. Step 1: Look at pH Step 2: Determine which is in the normal range Step 3: Combine names Possible causes pH PaCO2 HCO3- Diagnosis 7.35 to 7.45 35 to 45 21 to 28 Homeostasis Less than 7.35 Greater than 45 22-26 Respiratory Acidosis anesthesia, pneumonia, COPD, ARDS, PE, and overdose Less than 7.35 35-45 Less than 22 Metabolic Acidosis DKA, renal failure, dehydration, liver failure Greater than 7.45 Less than 35 22-26 Respiratory Alkalosis hyperventilation, early onset PE, mechanical ventilation, and fear Greater than 7.45 35-45 Greater than 26 Metabolic Alkalosis antacids, prolonged vomiting, and NG suctioning Metabolic alkalosis- provided ABGs needed to know what it was Select all that apply for metabolic alkalosis Dr. Blackburn Topic- NG tube: Under the Reduction of Risk Potential part of the NCLEX test plan there is a section titled Potential for Complications of Diagnostic Tests/Treatments/Procedures. Insertion, maintaining, and removing an NG tube is included in this part of the test plan. You should know best practices related to caring for patients with an NG tube. See IGGY 10th edition page 1102, which notes NG tube is needed for upper GI bleeding or obstruction. Care of patients with NG tube is noted on page 1113-1114. Make note of the action alert box in the left column page 1114 as well as the text on that page. Topic- informed consent: You are learning about legal issues/concerns week 4 in leadership/management. Informed consent is a legal concern. Consent is a defense for intentional torts. What is informed consent? Remember that consent must be obtained prior to any procedure and it must be voluntary. Consent can be revoked by the patient at any time. The provider is responsible for explaining the procedure, benefits, risks, alternatives, and answering all patient questions. The nurse may obtain patient signature on the consent form only after the provider has explained the procedure. If the patient has questions do not have them sign, call the provider. The nurse can sign as a witness to the patient's signature on the form but the nurse cannot sign for the client. Per page 490 in the 10th edition of Nursing Today, informed consent in the health care setting is a process whereby a patient is informed of: 1. The nature of the proposed care, treatment, services, medications, interventions, or procedures. 2. The potential benefits, risks, or side effects, including potential problems related to recuperation. 3. The likelihood of achieving care, treatment, and services goal. 4. Reasonable alternatives and their respective risks and benefits including the alternative of refusing all interventions. Informed consent correct understanding- patient has to be capable of making decisions Dr. Blackburn Week 5 You are the nurse providing care for a client with a history of glaucoma and Type 2 DM admitted with HHS: Topic-Hyperosmolar Hyperglycaemic State (HHS): Because fluid imbalance is potentially life threatening with HHS, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. These patients have fluid volume deficit. Many times, correcting the fluid volume deficit itself can lower serum glucose levels. Fluids are the priority with HHS. See page 1215 in IGGY 10th edition. HHS treatment addresses fluid replacement first (NS or 1/2 NS) to increase blood volume then IV insulin is added after adequate fluids have been replaced. Topic-Prevention of Venous Thromboembolism (VTE): Try this practice question from NCLEX category: Basic Care and Comfort, Mobility/Immobility A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? 1. Encourage the client to perform antiembolic exercises every 2 hr. 2. Instruct the client to cough and deep breathe every 4 hr. 3. Restrict the client’s fluid intake. 4. Reposition the client every 4 hr. Answer: 1 1. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation. 2. Instruct the client to cough and deep breathe every 1 to 2 hr to reduce the risk of atelectasis/pneumonia. 3. Increase the client’s intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction. 4. Reposition the client every 1 to 2 hr to reduce the risk for pressure injuries. As you learned in Med/Surg prevention of VTE is very important. This includes educating patients about smoking cessation, weight reduction, hydration, and increased physical activity. A patient has arrived to the Emergency dept with burns to the chest and abdomen (anterior trunk) and the entire right arm and right leg. Using the rule of nines, what is the percentage burn for this patient? The anterior trunk is 18%, the entire right arm is 9%, and the entire right leg is 18% for a total of 45% estimated body surface that has been burned. I recommend you know the rule of nines for estimating burn percentage. See page 461 in IGGY 10th edition textbook. Dr. Blackburn Topic- Abuse: Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. Elder abuse most often occurs when older adults are mistreated by someone with whom they have a trusting relationship — most often a spouse, sibling, child, friend or caregiver. Older adults may depend on the caregiver due to poor health and this makes them more vulnerable for abuse. For various reasons such as fear and disappointment, most of these cases go unreported. The potential for violence against an older adult is highest in families where violence has already occurred. Abusers have episodes of escalation and de-escalation with abuse, which usually continue with shorter and shorter periods of time between the two without intervention. Complete a thorough assessment of personal injuries noted in patients of any age. Topic-Prevention of Venous Thromboembolism (VTE): Try this practice question from NCLEX category: Basic Care and Comfort, Mobility/Immobility A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? 1. Encourage the client to perform antiembolic exercises every 2 hr. 2. Instruct the client to cough and deep breathe every 4 hr. 3. Restrict the client’s fluid intake. 4. Reposition the client every 4 hr. Answer: 1 1. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation. 2. Instruct the client to cough and deep breathe every 1 to 2 hr to reduce the risk of atelectasis/pneumonia. 3. Increase the client’s intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction. 4. Reposition the client every 1 to 2 hr to reduce the risk for pressure injuries. As you learned in Med/Surg prevention of VTE is very important. This includes educating patients about smoking cessation, weight reduction, hydration, and increased physical activity. Teach if traveling or sitting for long periods, do leg exercises (foot pumps, ankle circles, leg raises, etc), get up frequently and drink plenty of fluids. Get up for 5 minutes per hour. Avoid crossing legs. Change positions often. Dr. Blackburn Topic- Physical assessment (lung sounds): Most victims of elder abuse are frequently seen in the emergency department several times before they are admitted to the hospital. Respiratory and cardiac assessment is important for all patients. Students sometimes have trouble remembering correct assessment technique for auscultating heart and lung sounds as well as correct descriptions of lung sounds. Where would you place the stethoscope to auscultate the pulmonic valve and what are considered normal breath sounds? Place the stethoscope on the second intercostal space, LEFT of the sternal notch, to auscultate opening and closing sounds of the pulmonic valve. This is the opposite side of the sternal notch for auscultating the aorta opening and closing, which would be second intercostal space, right sternal notch. You should know where to place the stethoscope to listen to lung and heart sounds. This is fundamental nursing knowledge. Normal breath sounds include bronchial, bronchovesicular, and vesicular depending on the areas auscultated. See IGGY med/surg book for details on normal vs abnormal breath sounds. Characteristics of Normal Breath sounds are in table 24.4 in IGGY 10th edition book. Auscultation is the process of listening to sounds the body produces to identify unexpected findings. Some sounds are loud enough to hear unaided (speech and coughing), but most sounds require a stethoscope or a Doppler technique (heart sounds, air moving through the respiratory tract, blood moving through blood vessels). Learn to isolate the various sounds to collect data accurately. ● Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like). ● Use the diaphragm of the stethoscope to listen to high-pitched sounds (heart sounds, bowel sounds, lung sounds). Place the diaphragm firmly on the body part. ● Use the bell of the stethoscope to listen to low-pitched sounds (unexpected heart sounds, bruits). Place the bell lightly on the body part. Bronchial over trachea Dr. Blackburn Topic- Suspected child abuse: Nurses must report any suspicion of abuse (child or elder abuse, adult violence) following facility policy. Always make sure to complete a thorough assessment of injuries to determine how they may have occurred before contacting authorities. For children presenting with bruises don’t always assume it is abuse. Kids playing in skate parks and other physical outdoor sports may have injuries that result in bruising/injuries. Topic- Coping mechanisms: Try this practice question and include a rationale for your response. The nurse is caring for a client that recently underwent a colostomy procedure for cancer. Which of the following indicates the client is adapting well to body image changes? 1. The client names his brother as the person to call if he is experiencing suicidal ideation 2. The client continuously looks at the stoma and bag 3. The client is focused on his career and discusses a date to return to work 4. The client is requesting information on community resources for support Answer: 4. Requesting information on community resources available for support is positive channeling of energies, which indicates effective coping mechanisms. (breast cancer- tries prosthetics) Fetal distress is associated with FHR below 110/min or above 160/min, decreased or no variability. fetal hyperactivity, or no fetal activity. Additional manifestations of fetal distress are late decelerations associated with absent or minimal variability, recurrent variables, and prolonged decelerations. What are the causes of late deceleration, variable deceleration, and early deceleration of FHR? VEAL CHOP Fetal Heart Decelerations Decelerations Cause V = variables C = cord compression E = early decelerations H = head compression A = accelerations O = ok, outstanding L = late decelerations P = placental insufficiency, lack of fetal reserve Variable deceleration can indicate cord compression. Early decelerations can indicate fetal head compression. Persistent and consistent late decelerations with 50% or more of the contractions is suggestive of uteroplacental insufficiency. The first action of the nurse if fetal distress is noted: turn the mother L side; start oxygen at 8-10 liters by mask. Increase the IV infusion; if indicated. If oxytocin is being administered, it should be turned down or off with fetal distress. Dr. Blackburn Topic- FHR: You learned about electronic fetal monitoring in the maternity course. A normal fetal heart rate (FHR) baseline at term is 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. Changes in FHR include accelerations and decelerations. ● Variable deceleration can indicate cord compression. ● Early decelerations can indicate fetal head compression. ● Persistent and consistent late decelerations with 50% or more of the contractions is suggestive of uteroplacental insufficiency. The first action of the nurse if fetal distress is noted: turn the mother to the side; start oxygen at 8-10 liters by mask. Increase the IV infusion; if indicated. If oxytocin is being administered, it should be turned down or off with fetal distress. Topic- Placental separation: Try this ATI practice question from NCLEX® Category: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care. A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (Select all that apply) 1. Lengthening of the umbilical cord 2. Swift gush of clear amniotic fluid 3. Softening of the lower uterine segment 4. Appearance of dark blood from the vagina 5. Fundus firm upon palpation Include a rationale for your response(s). Answer: 1, 4, and 5. 1. CORRECT: The umbilical cord lengthens as the placenta is being expulsed. 2. A sudden gush of clear amniotic fluid occurs when membranes rupture, which occurs prior to the third stage of labor. Expected findings with amniotic fluid are clear, the color of water, and free of odor. Abnormal findings should be reported, which include bloody fluid from vagina (question for rupture of membranes) or the presence of meconium, abnormal color (yellow, green), and a foul odor. 3. Softening of the lower uterine segment is not an indication of placental separation. Remember that during the postpartum period nurses must monitor for uterine atony. Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone and prevent hemorrhage. 4. CORRECT: A gush of dark blood from the vagina is an indication of placental separation. This is expected when the placenta is expelled during the third stage of labor. However, if occurs before birth this needs to be reported as it is associated with significant maternal and fetal morbidity and mortality. 5. CORRECT: The uterus contracts firmly with placental separation in the third stage of labor. Dr. Blackburn Week 6 You are the nurse providing care for a client admitted with GI bleed and has history of Peptic Ulcer Disease (PUD) and high cholesterol. Nutrition is an area where many students need to increase their knowledge. It is important to understand nutritional teaching points for patients with CHD (Coronary Heart Disease), which is a leading cause of death in this country. As the nurse providing teaching to a client who has CHD, what specific points will you include in the teaching? Include specific information on nutritional recommendations. For patients with CHD, teaching points include: (no poached eggs… egg yolk contains cholesterol) ● HDL is good cholesterol and LDL is bad cholesterol. The goal is to have a high HDL level and a low LDL level. ● Secondary prevention efforts for CHD are focused on lifestyle changes that lower LDL. These include a diet low in cholesterol and saturated fats, a diet high in fiber, exercise and weight management, and cessation of nicotine use. ● Daily cholesterol intake should be less than 200 mg/day. Saturated fat should be limited to less than 7% of daily caloric intake. 1. Offering advice 2. Reflecting 3. Listening attentively 4. Giving information Answer: 1 1. CORRECT: Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends to interfere with the client’s ability to make personal decisions and choices. 2. The technique of reflection directs the focus back to the client in order for the client to examine his feelings. 3. The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey. 4. Giving information informs the client of needed information to assist in the treatment planning process. Clarifying techniques are useful to help the nurse determine if the message received was accurate: ● Restating: Uses the client’s exact words. ● Reflecting: Directs the focus back to the client in order for the client to examine his feelings. ● Paraphrasing: Restates the client’s feelings and thoughts for the client to confirm what has been communicated. ● Exploring: Allows the nurse to gather more information regarding important topics mentioned by the client. If a patient is upset but doesn't want to discuss something troubling, silence is a therapeutic communication technique. It is appropriate to offer to sit with the patient for awhile. Silence is a time for the nurse and client to observe one another, sort out feelings, think of how to say things, and consider what has been verbally communicated. The nurse should allow the client to break the silence. Dr. Blackburn you are the nurse caring for a client experiencing alcohol withdrawal who has a history of seizure disorder and is prescribed carbamazepine. You learned about alcohol withdrawal in mental health. Withdrawal occurs when concentration of the substance in the client’s bloodstream declines and the client experiences physiological adverse effects. Withdrawing from a substance that has the potential to cause abstinence syndrome can lead to distressing manifestations that are potentially life-threatening. You noted some s/s of alcohol withdrawal. What are other manifestations of alcohol withdrawal and what medications are administered to these patients? Important information to know about alcohol withdrawal: Manifestations usually start within 4 to 12 hr of the last intake of alcohol and can continue 5 to 7 days. Common manifestations include nausea; vomiting; tremors; restlessness and inability to sleep; depressed mood or irritability; increased heart rate, blood pressure, respiratory rate, and temperature; diaphoresis; tonic‑clonic seizures; and illusions. Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic effects (hallucinations), severe hypertension, and cardiac dysrhythmias. This type of withdrawal can progress to death. Medication to administer for patients experiencing alcohol withdrawal include: ● Benzodiazepines ● Chlordiazepoxide ● Diazepam ● Lorazepam ● Oxazepam Intended effects of these medications: ● Maintenance of vital signs within expected reference ranges ● Decrease in the risk of seizures ● Decrease in the intensity of withdrawal manifestations ● Substitution therapy during alcohol withdrawal NURSING ACTIONS for these meds: ● Administer these medications around‑the‑clock or PRN. ● Obtain baseline vital signs. ● Monitor vital signs and neurologic status on an ongoing basis. ● Provide for seizure precautions. ● Have flumazenil, a benzo antagonist, available if needed to reverse the effects of benzodiazepines. Adjunct medications include carbamazepine to decrease risk of seizures. Clonidine, propranolol, and atenolol may be administered to depress autonomic response (low BP and HR). Propranolol and atenolol also help to decrease craving. NURSING ACTIONS for these adjunct meds: ● Implement seizure precautions. ● Obtain baseline vital signs and continue to monitor. ● Check heart rate prior to administration of propranolol, and withhold if less than 60/min. Dr. Blackburn Topic-epilepsy: Seizures are an abrupt, abnormal, excessive, and uncontrolled electrical discharge of neurons within the brain that can cause alterations in the level of consciousness and/or changes in motor and sensory ability and/or behavior. Epilepsy is the term used to define chronic recurring abnormal brain electrical activity resulting in two or more seizures. Seizures resulting from identifiable causes, such as substance withdrawal or fever, are not considered epilepsy. Topic- Carbamazepine: Try this practice question from NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration and include a rationale for your response. A nurse is preparing a teaching plan for a client who has a new prescription for carbamazepine. Which of the following instructions should the nurse include in the teaching? Select all that apply. 1. “This medication can safely be taken during pregnancy.” 2. “Eliminate grapefruit juice from your diet.” 3. “You will need to have a complete blood count and carbamazepine levels drawn periodically.” 4. “Notify your provider if you develop a rash.” 5. “Avoid driving for the first few days after starting this medication.” Answer: 2, 3, 4, 5. 1. Carbamazepine is a Pregnancy Category Risk D medication. The client should be instructed to avoid pregnancy while taking carbamazepine and to use a ● For g tube or j tube rotate tube 360 degrees each day and notify provider if tube cannot be moved. ● Check residual every 6 hrs or per agency policy for clients receiving enteral feedings to decrease the risk of aspiration. Do not discard the residual. Follow facility policy as most or all of the residual should be replaced into the patient’s stomach to prevent fluid, electrolyte, and nutrient loss. ● For continuous feedings add only 4 hours of product to the bag at a time to prevent bacterial growth. Discard unused open cans after 24 hours. ● Change feeding bag and tubing every 24-48 hours. Replace irrigation set at least every 24 hours. ● Do not use any food dye color in formula. ● Keep HOB elevated at least 30 degrees during the feeding and for at least 1 hour after the feeding (if bolus feedings) to prevent aspiration. For cyclic or continual feedings maintain semi-Fowler’s position. ● A clogged tube is the most common problem. Flush tube with water: ○ Every 4 hours during continuous tube feedings ○ Before and after intermittent tube feeding ○ Before and after drug administration ○ After checking residual volume Dr. Blackburn Monitor for changes in level of consciousness with stroke patients, which indicates increased ICP. Watch for irritability, restlessness, or agitation and report. The Glasgow Coma Scale is used when the client has a decreased level of consciousness or orientation. The risk for increased intracranial pressure (ICP) exists related to the swelling of the brain that can occur secondary to ischemic insult. Try this practice question and include a rationale for your response: A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? Provide a rationale for your response. 1. Position the client sitting up in bed before feeding. 2. Check the client’s gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client’s secretions between bites of food. Answer: 1. Positioning the client in a sitting position decreases the risk of aspiration. Instructing the patient to also tilt their head forward will help decrease the risk of aspiration. The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing. (question was a spouse making a statement that needed further teaching… i believe it said something like i will instruct my spouse not to tilt head forward) 2 is not correct. The UAP is not trained to assess gag or swallowing reflexes. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client’s swallowing ability should be assessed, and suctioning can be needed if choking occurs. Suction equipment should be available in case of choking and aspiration. 3 is not correct. The client should not be rushed during feeding. Place food on the unaffected side of the client’s mouth, which will allow them to have better control of the food and reduce the risk of aspiration/pocketing food. Observe for indications of dysphagia (change in voice, coughing, choking, gagging, and drooling of food). 4 is not correct. A client who needs suctioning performed between bits of food is not handling secretions and is at risk for aspiration. This type of client would need to be assessed further by the RN or SLP before feeding. Dysphagia is common in patients that have had a stroke. A speech-language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties. The client should be given liquids that are thicker than water to prevent aspiration. Dr. Blackburn Week 7 you are the oncology nurse providing care for a client receiving concurrent chemoradiation including external beam radiation therapy for cervical cancer and is asking questions about hospice. Sometimes student confuse care of patients receiving external beam radiation vs care of those with internal radiation treatment. Radiation therapy can be administered internally (brachytherapy) with an implant or externally (teletherapy) with a radiation beam. The type used depends on the health of the client and shape, size, and location of the tumor. External beam radiation therapy does not cause the client to become radioactive. Page 382 in IGGY 10th edition notes skin protection during radiation therapy. Entry level nurses should be familiar with these teaching points. What are best practices to implement when caring for patients with a sealed implant for internal radiation? Internal radiation causes body fluids to be contaminated with radiation, and body wastes should be disposed of appropriately, as directed by the facility. See page 381 in IGGY 10th edition for care of the patient with a sealed implant. Entry level nurses should be familiar with this information. ● Private room/keep door closed. ● Each visitor is limited to one-half hour per day and should state at least 6 feet from the source of radiation. ● Children under 16 and pregnant women are not allowed to visit. ● Nurses must wear a lead apron while providing care. Visitors are not required to wear a lead apron. ● Each nurse caring for the patient should wear a dosimeter film badge at all times, which measures exposure to radiation. ● Dressings and linens are kept in the room until source removed. ● Equipment does not pose a hazard and can be removed from the room at any time. (further teaching questions says they cannot remove equipment from room) Dr. Blackburn Cancer cells can invade surrounding tissues and spread to other areas of the body through lymph and blood vessels (metastasis). No matter where cancer spreads, it always is named based on the origin in which it started. For example, colon cancer that spreads to the liver is called metastatic colon cancer. Metastasis is usually diagnosed when there is onset of new findings (bone pain indicative of bone metastasis; change in bowel or bladder tone indicative of nervous system involvement). Patients you care for may become anemic, cancer patients often experience anemia from chemotherapy. Try this practice question and provide a rationale for your response: You are caring for a client who has a hematocrit of 28 mg/dL. The provider prescribes iron supplementation. Which teaching should the nurse provide? Select all that apply. 1. "Take the iron pill in the morning with eggs." 2. "Take the iron pill every other day for best benefit” 3. "Eat some strawberries when taking the iron pill." 4. "Drink a full glass of milk when taking the iron pill." 5. "Drink a glass of orange juice when taking the iron pill." Answers 3 and 5 are correct. Constipation can impede the flow so an enema prior may also be indicated. The patient should also use stool softeners and eat high-fiber foods. Dr. Blackburn Chronic Glomerulonephritis leads to ESRD due to damage that occurs which allows protein to enter urine. As urine output decreases fluid overload is a concern. Monitor closely for manifestations of fluid overload and report immediately. Listen to lungs for crackles, assess HR and rhythm. Inspect neck veins for venous engorgement and check feet/ankles for edema. Glomerular filtration rate is low for these patients, which ends up leading to ESRD. Legal content was covered week 4 in Leadership. The legal material includes the two categories of torts: unintentional and intentional. What are examples of unintentional torts and intentional torts? Per page 468 in the Nursing Today 10th edition book intentional torts are “wrongs” done on purpose to harm another individual. Assault and battery as well as false imprisonment are intentional torts. Threatening to keep a patient from leaving or threatening a patient with restraints (chemical or physical) is false imprisonment and is associated with assault and battery claims. Assault is the threat of touch and battery is actual touching. You should know the difference. Defamation refers to libel and slander causing damage to someone else’s reputation. If the defamation is verbally expressed this is slander. If the defamation is written it is libel. Another example of an intentional tort is invasion of privacy. Nurses are responsible to protect confidentiality of patients. Never photograph a patient or procedure without consent and post to social media or show it to another person. Never discuss a patient in public. I recommend you know what constitutes intentional torts. Unintentional torts include negligence and malpractice. Negligence: Practice or misconduct that does not meet expected standards of care and places the client at risk for injury (a nurse fails to implement safety measures for a client who has been identified as at risk for falls). A nurse is considered negligent when unintentionally causing personal harm or injury when the nurse should have acted reasonably to avoid harm. Malpractice: Professional negligence (a nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies). Dr. Blackburn Thanks for your response. Acute and chronic glomerulonephritis can develop from a systemic infection and involves the glomeruli of the kidney or the area responsible for filtering particles from the blood to make urine. Expected findings: ● Anorexia ● Nausea ● Dysuria ● Oliguria ● Fatigue ● Hypertension ● Difficulty breathing ● Crackles ● S3 heart sound ● Weight gain ● Reddish-brown or cola-colored urine ● Older adult clients likely to have the less common manifestations related to circulatory overload, which can be confused with congestive heart failure. Try this practice question and provide a rationale for your answer: Checking for the return of the gag reflex and monitoring for LUQ pain, nausea and vomiting are necessary nursing actions after which diagnostic procedure? a. ERCP b. Barium swallow c. Colonoscopy d. Esophagogastroduodenoscopy (EGD) Answer: a. The left upper quadrant (LUQ) pain and nausea and vomiting could occur from perforation with ERCP. Air is instilled during the procedure so mild abd pain (colicky) and flatulence are expected post procedure. Instruct the patient to report severe abd pain, fever, nausea, or vomiting. Post procedure monitor VS every 15 minutes until stable and institute aspiration precautions. The return of gag reflex is essential to prevent aspiration after an ERCP as the patient will receive sedation drugs during the procedure. Keep the patient NPO until the gag reflex has returned. The gag reflex is also assessed with an EGD but the LUQ assessment is specific to the ERCP. These are not relevant assessments for the colonoscopy and barium swallow. As noted in IGGY page 1068, teaching for the ERCP procedure should include NPO for 6-8 hrs before the test. ERCP difficulty swallowing Dr. Blackburn you are the nurse in a well child clinic performing a developmental screening on an 18-month-old child that is unable to walk without assistance and both parents have a history of substance abuse. Entry level nurses should know expected growth and development milestones in order to recognize developmental delays. An 18-month-old child that is unable to walk without assistance may have a developmental delay, be sure to notify the provider. Walking without help is expected by 15 months of age. Topic- Car seat safety: You learned about safety for pediatric patients in your Maternity/Peds class. What are important teaching points for parents regarding car seat safety for children? Newborn infants should be placed in a federally approved car seat at a 45 degree angle to prevent slumping and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness should be snug and the retainer clip placed at the level of the infant’s armpits. Infants should remain in a rear facing car seat at least until age 2. All infants and toddlers should ride in a rear-facing seat until they reach the highest weight or height allowed by their car seat manufacturer. Most convertible seats have limits that will allow children to ride rear facing for at least 2 years. After outgrowing the rear-facing car seat, use a forward-facing car seat until at least age 5. ● When children outgrow their rear-facing car seats, they should be buckled in a forward-facing car seat, in the back seat (middle preferred unless seat doesn’t fit), until they reach the upper weight or height limit of their car seat. ● Stands securely ● Walks holding on to furniture or with both hands held 12 Months: ● Walks with one hand held ● Attempts to stand alone momentarily 15 Months: ● Walks without help ● Crawls up stairs ● Builds a tower of two blocks ● Uses cup well ● Rotates spoon before reaches mouth Dr. Blackburn Entry levels nurses are expected to know age appropriate growth and development milestones. Try this practice question and include a rationale for the answers you select: A nurse is assessing a 4-year-old child. What age-appropriate language skills does the nurse expect the child to have achieved? Select all that apply. 1. Uses appropriate grammar 2. Uses 4- and 5-word sentences 3. Asks the meaning of new words 4. Pronounces the sounds CH and TH 5. Has a vocabulary of 1500 words Answer: 2, 5 2 is correct. Because of developing cognitive abilities, 4-year-old children can form 6- to 8-word sentences. 5 is correct. Because of expanded experiences and developing cognitive ability, the 4-year-old child should have a vocabulary of approximately 1500 words 1 is not correct. The use of appropriate grammar does not develop until about 9 to 12 years of age. 3 is not correct. By 5 to 6 years of age, children ask the definitions of new words; 4-year-old children have not yet achieved this level of development. 4 is not correct. By 4 to 5 years of age children's speech is intelligible although sounds such as CH, TH, SH, Z, R, and L frequently are imperfect. Dr Blackburn Week 8 you are the ED nurse providing care for a client with a GSW to abdomen and monitor shows v-fib rhythm. Nurses must have the ability to identify emergent situations and rapidly assess and intervene when life-threatening conditions exist. Emergent conditions are common to all nursing environments. Nursing priorities for trauma victims that present in the Emergency Dept with GSW include: ● After airway and breathing are ensured for trauma victims with GSW/active hemorrhage, we need to focus on stopping the bleeding and replacing fluids/blood lost. ● Firm direct pressure is indicated to help stop the bleeding if there is significant external bleeding. ● Obtain IV access with a 16-gauge (large bore needle) in the antecubital space. Infuse isotonic IV fluids such as lactated Ringer’s and 0.9% sodium chloride, and/or blood products. You previously learned about triage and discharging patients when beds are needed during a disaster. What type of patients could be discharged early in a disaster situation to free up beds in an acute care facility? In a mass casualty situation where beds are needed the most medically stable may be discharged early. Patients with acute conditions requiring treatment are not appropriate for discharge. Medically stable patients include observation patients not bedridden, patients admitted for diagnostic procedures, those scheduled for discharge soon, and patients that can be discharged with home health or family support. Dr. Blackburn Preserving forensic evidence is essential for investigative purposes following injuries that may be caused by criminal intent. The nurse should not handle bullets from the client because they are an important piece of forensic evidence. Health Promotion and Maintenance category covers care of patients for all ages, which includes stages of development as noted in page 18 of the NCLEX-RN Test Plan. Try this Health Promotion and Maintenance practice question. Be sure to include a rationale for your response. A pediatric nurse would be concerned by which of the following? 1. Newborn: HR 165, RR 45 2. 15-month-old: HR 158, RR 50 3. 8-year-old: HR 88, RR 20 4. 13-year-old: HR 70, RR 18 Answer 2 would be a concern. A 15-month-old child should not have a HR of 158 and RR of 50. Normal vital signs for a toddler: heartrate of 80-140 (slight increase is okay if very active), BP 90-105/55-70 mm Hg, Temp 97.6-99.5° F, and Respirations 22-37. The other findings are expected for the age range noted. I recommend you know normal VS for children/newborns so you can recognize abnormal when tested on the information. The standardized values document in the course resources module has the information you need to know. Dr. Blackburn you are the nurse providing care for a client with a history of myasthenia gravis admitted with angina and PVCs. Manifestations of MG include muscle weakness and fatigue, trouble swallowing and chewing/dysphagia, ptosis, diplopia, respiratory compromise including diminished breath sounds, difficulty breathing, and respiratory paralysis/failure. If any of these manifestations present it is a priority to follow-up. Treatments for MG include immunosuppressants and cholinesterase (ChE) inhibitors, which should be administered on time to maintain blood levels and improve muscle strength. Pyridostigmine is one of the ChE inhibitors used to treat MG. Try this practice question and provide a rationale for your response: A nurse is admitting a client who has acute adrenal insufficiency. Which of the following would you expect to be prescribed for this client? (Select all that apply.) 1. Potassium 3.8 mEq/L 2. BUN 11 mg/dL 3. AST 30 units/L 4. LDL 170 mg/dL 5. Sodium 141 mEq/L Answer: 4. The LDL level is elevated and may indicate the client is noncompliant with taking the statin medication. Remember the goal with cholesterol levels is a low LDL level and high HDL level. Make sure you understand normal for these values so you can provide correct referrals and teaching to patients with high cholesterol. We would monitor the liver enzymes for patients taking a statin but in this case the AST level is normal. Statin meds can cause rhabdomyolysis, which could increase BUN and K levels, but the lab values for these are within normal limits. The sodium level is also within normal limits. Entry level nurses should also have knowledge of dietary teaching points for patients with high cholesterol levels. Dr. Blackburn you are the nurse caring for a client admitted with Pulmonary Embolism receiving Heparin IV and has an order to start enoxaparin. For patients experiencing a PE, heparin therapy is usually prescribed for at least 5 days. Warfarin is also started on most patients on day one or two of heparin therapy. The patient will receive both heparin and warfarin until the INR reaches 2-3. Heparin is infused for 24 hours after the INR is greater than 2 then the heparin is discontinued. The overlap period of at least 5 days for warfarin and heparin is necessary because the drug action of each is different. Warfarin works in the liver to inhibit synthesis of Vit K dependent clotting factors and takes 3-4 days before therapeutic effect is realized. Medication Administration is part of the Pharmacological and Parenteral Therapies section of the NCLEX test plan, which includes review pertinent data prior to medication administration (e.g., contraindications, lab results, allergies, potential interactions). As an entry level nurse, it is important that you understand monitoring of lab values for patients prescribed anticoagulants such as heparin and warfarin. What are normal values of PT/INR, PTT, and aPTT for these patients? Prothrombin Time PT • Normal is 11-12.5 seconds • 1.5-2.5 times the normal control (~16-31) for patients receiving warfarin International Normalized Ratio INR • Normal is 0.9-1.2 seconds • Desirable therapeutic level is 2-3 times the normal for patients receiving warfarin • For patients with mechanical heart value replacement an INR of 3 - 4 may be the goal. Partial thromboplastin time PTT • Normal PTT is 20-30 seconds • 1.5-2.5 times the normal control (30-75) for patients receiving heparin Activated partial thromboplastin time aPTT • Normal is 30-40 seconds • 5-2.5 times the normal control (45-100) on Heparin Dr. Blackburn In Pharm and med/surg you learned about enoxaparin, a low molecular weight (LMW) heparin. Low molecular weight heparins (ie; enoxaparin) are often prescribed to prevent deep‑vein thrombosis (DVT) in clients who are postoperative. Nursing implications/teaching for patients receiving enoxaparin: ● Provide instruction regarding self-administration. Do not expel the air bubble in the syringe. It’s nitrous oxide and allows the client to receive all the medication during the injection. Do not aspirate. Inject entire contents of syringe. Do not rub the site for 1 to 2 min after the injection. Rotate and record injection sites. ● Avoid over‑the‑counter medication unless prescribed by a provider. Avoid the use of OTC NSAIDs, aspirin, or medications containing salicylates. ● Don’t take enoxaparin with garlic, ginger, ginkgo, or feverfew. These supplements may increase the risk of bleeding. ● Monitor for indications of bleeding, (bruising, gums bleeding, abdominal pain, nose bleeds, coffee‑ground emesis, and tarry stools). ● Use an electric razor for shaving and brush with a soft toothbrush. ● Bloodwork monitoring of platelets is recommended. Try this practice question and provide a rationale for your response: The nurse is administering medications on a med/surg unit. Which of the following prescriptions would require follow-up with the provider? 1. Desmopressin for client diagnosed with Diabetes Insipidus. 2. Fludrocortisone for client with Addisonian crisis. 3. LMWH injection for client with thrombocytopenia. 4. Sodium polystyrene sulfonate for client with kidney disease. Answer 3 requires follow-up. 1 does not need follow-up. Desmopressin is an appropriate medication for DI to replace ADH and decrease urination. 2 does not need follow-up. Fludrocortisone is often prescribed for patients with adrenal hypofunction (Addison disease). Monitoring BP is a priority with this medication due to risk of hypertension. 3 requires follow-up. Thrombocytopenia is a decrease in platelets that leads to impaired clotting and bleeding. LMWH is not appropriate for a patient with thrombocytopenia and would require follow-up. 4 does not need follow-up. Sodium polystyrene sulfonate (Kayexalate) may be prescribed for patients with kidney disease because it absorbs and lowers potassium. Dr. Blackburn Unfractionated heparin is an anticoagulant indicated for both the prevention and treatment of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as atrial fibrillation (AF). Interventions for PE include: ● Oxygen therapy – mechanical ventilation may be indicated for patients with severe hypoxia ● Close monitoring of ABGs and Oxygen saturation ● Continuous monitoring for complications ● Sleep with the HOB elevated 6-12 inches ● Teach these patients to avoid eating for 3 hours before bedtime. Eating before going to bed will exacerbate GERD ● Avoid caffeine and spicy foods, which can exacerbate GERD Dr. Blackburn Thanks for your response. Although a cardiac cath is the most invasive test used to diagnose heart disease it is very useful as a definitive test. Try this practice question and provide a rationale for your response: The registered nurse has received change of shift report. Which of the following patients should the nurse assess first? 1. Client with chest tube drainage of 65mL in the last hour and pulse ox is 92% 2. Client 1 day post abdominal surgery has a Jackson Pratt drain that needs irrigated and amount of drainage documented 3. Client with tumor lysis syndrome, is lethargic and complains of n/v, and has a potassium level of 5.0 4. Client with portal hypertension and a change in BP from 138/82 to 110/60 over the last 2 hours Answer: #4 All the patients will be assessed but #4 is the priority. Portal hypertension is an increase in pressure within the portal vein. It is a major complication of cirrhosis that can lead to bleeding esophageal varices, a medical emergency. Patients with a change in VS, especially with BP changing at least 20 points (or another significant change over a short timeframe) needs assessed by the RN. This patient could be bleeding from esophageal varices. #1 is not correct as 65mL/hr is considered normal chest tube drainage. The oxygen saturation level will need monitoring and if it drops below 90% immediately notify surgeon as noted on page 561 in IGGY 10th edition. #2 is not correct. The nurse will need to irrigate the JP and cannot delegate this task, but this is not the priority patient. The UAP can empty and record output for JP but cannot irrigate. #3 is not correct. Patients with TLS are expected to have high K levels with lethargy and n/v. This patient is on the high end of normal for K level and will need to be assessed but is not the first priority. Dr. Blackburn you are the nurse providing care for a client with narcissistic personality disorder who wants to leave AMA. A client who has a personality disorder demonstrates pathological personality characteristics including impairments in self-identity/self-direction and interpersonal functioning. The maladaptive behaviors of a personality disorder are not always perceived by the individual as dysfunctional, and some areas of personal functioning can be adequate. When a patient wants to leave AMA remember they have the right to leave the hospital against medical advice. The nurse should not prevent a client from leaving by any action. Threatening to keep a patient from leaving is false imprisonment and is associated with assault and battery claims. Assault is the threat of touch and battery is actual touching. Expect questions on health promotion and disease prevention on Comp exams, NCLEX, and ATI. Disease prevention (including cancer) is divided into primary, secondary, and tertiary prevention. What is the difference in primary and secondary prevention? Provide examples of secondary prevention strategies for cancer and primary disease prevention strategies. Primary prevention includes interventions that keep a cancerous process from ever developing. Primary prevention addresses the cause of cancer, so disease does not occur. Examples of primary prevention strategies are stress reduction techniques, avoiding tobacco products and red meat as well as limiting alcohol intake to 1 ounce per day, and adding fruits/veggies/whole grains to diet. Primary prevention is focused on modifying associated factors, avoidance of known or potential carcinogens, vaccines (HPV), stress reduction, and removal of at-risk tissues such as polyps or breast tissue as noted on page 373 in IGGY 10th edition. Chemoprevention is a newer strategy used to reverse existing gene damage. Examples include ASA and celecoxib to reduce colon cancer risk, lycopene to reduce risk of prostate cancer, and Vit D/Tamoxifen to reduce risk for breast cancer. Secondary prevention is the use of screening strategies to detect cancer early when cure or control is more likely. Secondary prevention identifies disease before the onset of symptoms and keeps it from becoming more extensive. Examples of secondary prevention strategies are interventions leading to the discovery and control of cancerous or precancerous processes while localized, i.e., screening and early detection. Breast self-exams (BSE) and testicular self-examination are examples of secondary prevention. Entry level nurses should know teaching for patients regarding testicular exams and BSE. IGGY 10th edition details teaching for BSE on page 1436-1437 and testicular exams on page 1486. Tertiary prevention reduces complications and progression of disease once it has become clinically apparent. Tertiary measures are focused on clinical stage, recovery, disability, or death stage. An example of tertiary prevention would be speech, physio- and occupational therapy and associated medical therapy, following a cerebrovascular accident. Another example, related more to the clinical stage, would be the management of diabetes. Their purpose is to reduce or eliminate long-term impairments and disabilities, minimize suffering, optimize function, assist in adjusting to limitations in health and function resulting from the event, and sometimes extend survival. Dr. Blackburn Narcissistic personality disorder is one of the Cluster B disorders presenting with dramatic, emotional, or erratic traits. How do the other Cluster B disorders present? Cluster B personality disorders include Antisocial, Borderline, and Histrionic as well as Narcissistic. Antisocial: Characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, failure to accept personal responsibility; evidence of conduct disorder before age 15, sense of entitlement, manipulative, impulsive, and seductive behaviors; nonadherence to traditional morals and values; verbally charming and engaging. Borderline: Characterized by instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often self-injurious and potentially suicidal; ideas of reference are common; often accompanied by impulsivity. Limit-setting and consistency are essential with clients who are manipulative, especially those who have borderline or antisocial personality disorders. Histrionic: Characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious. For clients who have histrionic personality disorder, who can be flirtatious, it is important for the nurse to maintain professional boundaries and communication at all times. Clients who have dependent and histrionic personality disorders often benefit from assertiveness training and modeling as well as psychotherapy. Dr. Blackburn you are the nurse providing care for a client with bacterial pneumonia receiving mechanical ventilation via tracheostomy. You learned about postmortem care in a previous course. What are appropriate nursing interventions to implement before the family views the patient? IGGY 10th edition page 146-147 covers postmortem care. After a terminally ill patient has died ask the family if they would like to spend time alone with the patient. Remember to consider cultural considerations. In some cultures, the family may prefer to clean the body, but this is not something we request. Nurses are responsible for following federal and state laws regarding requests for organ or tissue donation, obtaining permission for autopsy, ensuring the certification and appropriate documentation of the death, and providing postmortem care. PREPARING THE BODY FOR VIEWING (select all) ● Maintain privacy ● Remove all tubes and lines (unless organs are to be donated or this is a medical examiner’s/autopsy case – see below). ● Remove all personal belongings to be given to the family ● Cleanse and align the body supine with a pillow under the head, arms with palms of hand down outside the sheet and blanket, and eyes closed ● Insert the client’s dentures so that the face looks as natural as possible ● The body and the environment should be as clean as possible. This includes washing soiled areas of the body, replacing soiled pads/dressings with clean ones, ensuring pads are placed under patient in case of body fluids, and applying fresh linens and a clean gown. ● Brush/comb the client’s hair. Replace any hairpieces ● Remove excess supplies, equipment, and soiled linens from the room ● Dim the lights and minimize noise to provide a calm environment ● Ensure the physician has signed the death certificate. Although many states allow nurses to pronounce death in long-term care settings, most hospitals require the physician to pronounce and sign the death certificate (exam said coroner pronounces dead that is wrong) Medical Examiner Case: An autopsy is indicated if the cause of death is unknown or unexpected. An autopsy is not indicated for a terminally ill patient that dies. For patients where an autopsy is indicated, do not remove IV lines or another other indwelling tubes/catheters and do not clean the patient. This could destroy evidence in a case that requires the medical examiner. AUTOPSY CONSIDERATIONS ● The provider typically approaches the family about performing an autopsy. ● The nurse’s role is to answer the family members’ questions and support their choices. Autopsies are not allowed by some religions such as Orthodox Judaism. ● Autopsies can be conducted to advance scientific knowledge regarding disease processes, which can lead to the development of new therapies. ● The law can require an autopsy to be performed if the death is due to homicide, suicide, or accidental death, or if death occurs within 24 hr of hospital admission. ● Most facilities require that all tubes remain in place for an autopsy. ● Documentation and completion of forms following federal and state laws typically includes the following. ○ Who pronounced the death and at what time ○ Consideration of and preparation for organ donation ○ Description of any tubes or lines left in or on the body ○ Disposition of personal articles ○ Who was notified, and any decisions made ○ Location of identification tags (body and bag) ○ Time the body left the facility and the destination Dr. Blackburn Entry level nurses should be familiar with interventions including teaching for patients with Sickle Cell. For acute crisis manage severe pain with opioid analgesics for these patients. Apply comfort measures (warm packs to painful joints). Schedule administration of analgesics to prevent pain. Try this practice question and provide a rationale for your response. A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? 1. Pain in right upper quadrant radiating to right shoulder 2. Report of pain being worse when sitting upright 3. Pain relieved with defecation 4. Epigastric pain radiating to the left shoulder Answer: 4 1. NOT CORRECT. A client who has cholecystitis will report pain in the right upper quadrant radiating to the right shoulder. 2. NOT CORRECT. A client who has pancreatitis will report pain being worse when lying down. 3. NOT CORRECT. A client who has pancreatitis will report that pain is relieved by assuming the fetal position. 4. CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder. If pain intensifies with inspiration report to provider as this could indicate a pleural effusion or other respiratory complications. See action alert box page 1187 in IGGY 10th edition. Dr. Blackburn you are the nurse providing care for an older adult who has a history of atrial fibrillation and had a pacemaker inserted 24 hours ago for symptomatic bradycardia. We know patients with a-fib are at risk of throwing a clot that results in a PE. What manifestations would you monitor for while caring for the patient? Page 653 in IGGY 10th edition book has an action alert box explaining the risk of a PE/VTE/embolic stroke for patients with AF. Monitor for SOB, chest pain, and/or hypotension when PE is suspected. Monitor for s/s of stroke (you learned these in 242) and notify RRT if stroke suspected. For VTE monitor for and report lower extremity pain and swelling. Drug therapy is often effective to prevent embolus and increase cardiac output. Dr. Blackburn Thanks for your response. Synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT ), or ventricular tachycardia with pulse. If there is a history of atrial fibrillation, it is recommended the client take anticoagulant therapy for 4 to 6 weeks prior to cardioversion to prevent clot dislodgement. You learned about vaccines in the pediatric course. Often there are misconceptions that administering several vaccines at one time will overload the child’s immune system. This is a misconception and not supported by research. There are other misconceptions around contraindications for vaccines with pediatric patients. What are the contraindications for pediatric vaccines? The peds presentation includes contraindications for vaccines, which are: Pt wbc was low 3,900 you are the nurse providing care for a client with acute adrenal insufficiency experiencing manifestations of fluid depletion and electrolyte imbalances. Thanks for your response. A client with an exacerbation of adrenal insufficiency is at risk for falls. Postural hypotension may occur in patients with Addison’s disease. They may have severe hypotension - blood volume depletion d/t loss of aldosterone. Be sure to implement fall precautions as this is a safety risk. Try this NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Adverse Effects/Interactions practice question and include a rationale for your response. A nurse is caring for a client who has diabetes and is experiencing nausea due to gastroparesis. The nurse should expect a prescription for which of the following medications? 1. Lubiprostone 2. Metoclopramide 3. Bisacodyl 4. Loperamide Answer: 2 is correct 1. Not correct. Lubiprostone is a medication used to treat irritable bowel syndrome with constipation in women. 2. CORRECT: Metoclopramide is a dopamine antagonist that is used to treat nausea and also increases gastric motility. It can relieve the bloating and nausea of diabetic gastroparesis. 3. Not correct. Bisacodyl is a stimulant laxative that is used for short-term treatment of constipation. 4. Not correct. Loperamide is an antidiarrheal agent that decreases gastrointestinal peristalsis. Dr. Blackburn Loperamide for ibs question it because lubiprostone is given for ibs Thanks for your response. Adrenal insufficiency presents with muscle weakness, fatigue, joint/muscle pain. Monitor for hypoglycemia (check glucose levels) and fluid depletion as priorities when caring for these patients. Other manifestations include: ● GI symptoms (n/v, pain, anorexia, weight loss) ● Skin symptoms (vitiligo and hyperpigmentation) ● Cardiac symptoms (hypotension, hyponatremia, hyperkalemia, and hypercalcemia) Try this practice question: The nurse is caring for a child who has Varicella (chickenpox). Which infection control precaution should the nurse implement? Varicella (chickenpox) requires airborne precautions, which are indicated for diseases that are transmitted by air. Measles (rubeola), disseminated zoster (shingles) and TB are other diseases that require airborne precautions. You should know the type of precautions (airborne, droplet, and contact) required to prevent the spread of specific infections. There is a good table in the IGGY book. Know each disease appropriate for type of precaution listed and guidelines for each including which precautions require the patient to wear a mask during transport. (pt with pertussis should wear a mask during transport) Dr. Blackburn Addisonian crisis may be triggered by stress (e.g., from infection, surgery, trauma, or psychologic distress), sudden withdrawal of corticosteroid hormone therapy (often done by a patient who lacks knowledge regarding replacement therapy), adrenal surgery, or sudden pituitary gland destruction. During stressful situations, the glucocorticoid dosage is increased to prevent Addisonian crisis. The patient usually is instructed to take 2 to 3 times the usual dose. Try this practice question and include a rationale for your response. The registered nurse on a medical surgical floor is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin- resistant S. aureus (VRSA). A CVAD has been inserted for long-term medication administration. Which nursing action can you delegate to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake. 2. Teaching the client about home care of the leg ulcer. 3. Obtaining wound cultures during dressing changes. 4. Administering prescribed IV medications Answer: 3. The LVN can obtain wound cultures. The other options can only be done by the RN. LVN/LPNs can reinforce teaching after the RN has completed the initial teaching. The LVN can collect data the RN will use to develop the plan of care but the RN is responsible for developing the plan. I recommend you review appropriate delegation guidelines and tasks for RNs to LVNs/LPNs and UAP that was previously covered this term. Also, see legal/ethical review video in the faculty added content module. Dr. Blackburn Week 11/12 you are the nurse providing care for a client with polycystic kidney disease and proteinuria who needs a urine sample for C&S. Polycystic kidney disease (PKD) is a congenital disorder where clusters of fluid-filled cysts develop in the nephrons. PKD is hereditary and is caused by a genetic mutation. Teaching for these patients: ● Monitor blood pressure and weight daily. ● Notify the provider of elevated temperature. ● Adhere to a low-sodium diet. ● Inform the provider if there are any changes in urine or bowel movements. Dr. Blackburn Polycystic kidney disease (PKD) is a congenital disorder where healthy kidney tissue is replaced by multiple non-functioning cysts. Progressive kidney failure is an expected finding with these patients. Abdominal and/or flank pain can be dull, which indicates increased kidney size or possible cyst infection. Sharp pain indicates ruptured cyst or possible renal lithiasis (kidney stone). Assess urine for blood, stones, and particles indicating an obstruction of the urinary structures that leave the kidney, report to provider. Dr. Blackburn you are the nurse providing care for a client with latex allergy experiencing an acute asthma attack. Hypersensitivity to Latex is a concern for patients and for health care providers. An allergic reaction to latex is a Type I hypersensitivity reaction. The protein found in natural