Reduction of Risk Potential

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ATI REDUCTION OF RISK POTENTI...

66 terms shelby__chinen Preview Lesson 45 terms Jacq The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower leg. Which of the lab results would the nurse be most concerned about?

1. WBC 15,000

• Platelet count 50,000
• Hemoglobin 14 g/dL
• Hematocrit 45%
• PTT 55 seconds

1 Thrombocytopenia (abnormally low amount of platelets) and heparin-induced thrombocytopenia can occur in clients on heparin therapy. In an adult, a normal platelet count is about 150,000 to 450,000 platelets per microliter of blood (or 150-450 x 109/L). The PTT is within the therapeutic range. It is expected that the white blood cells would be slightly elevated in a client with an infection (cellulitis).The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question?

• Send three stool samples for occult blood
• Obtain complete blood count (CBC)
• Administer ranitidine (Zantac) 150 mg tab twice a day

by mouht

• Insert nasgogastric tube to gravity

4 Esophageal varices are similar to varicose veins within the esophagus. A nurse would never insert an NG tube if this diagnosis is suspected because it might rupture the varices and cause an acute hemorrhage. The other orders make sense during a GI work-up for anemia. Checking CBC will provide hemoglobin and hematocrit values to quantify the degree of anemia. Ranitidine decreases stomach acid and may decrease loss of blood through a possible ulcer. Getting stool samples for occult blood can identify the presence of small amounts of blood in the stool that are not visible to the naked eye.The nurse cares for a client who was admitted in status epilepticus and whose last seizure was four hours ago.What is the most important nursing assessment for this client?

• Vital signs and oxygen saturation
• Injuries to the extremities
• Respiratory status
• Level of consciousness

4 Cerebral blood flow surges during seizure activity, depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client's level of consciousness very closely.

A nurse is teaching a client with a diagnosis of metastatic bone disease about actions to prevent hypercalcemia. It would be important for the nurse to include which of these points?

• Early recognition of findings associated with tetany
• Walking as much as possible keeps the calcium in the

bone

• A restriction of fluid intake is to be less than one liter

per day

• At least five servings of dairy products are to be eaten

daily 2 Mobility must be emphasized to prevent demineralization and breakdown of bones. Weight-bearing and resistance exercises will assist in this process.A 62-year-old client is admitted to the emergency department. The client has a history of anemia and peptic ulcer disease and is now experiencing chest pain, nausea and dizziness. The nurse anticipates which laboratory tests to be ordered right away? (Select all that apply.)

• Helicobactor pylori (H. pylori)
• Cardiac enzymes
• Toxicology screen
• Lipid panel
• Complete blood count (CBC)

2, 5 Chest pain with nausea and dizziness may be findings associated with angina or myocardial infarction. Cardiac enzymes, including creatinine kinase, myoglobin, and troponin, are indicated to determine if muscle damage has occurred (to help rule out a heart attack). Low hemoglobin (Hgb) can precipitate an angina attack if there is not enough Hgb to deliver oxygen to the myocardium; given the client's history, a CBC would be indicated. There are no findings of either overdose or poisoning, so a toxicology screen is not needed. A lipid panel is used to show one's risk for coronary heart disease and the presence of Helicobacter Pylori is associated with increased cardiovascular disease risk and lower HDL, but these tests are not used diagnostically for chest pain.An X-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube.What action will the nurse take to verify tube placement?

• Measure the pH of aspirated gastric contents
• Auscultate for the sound of air produced by forcing air

through the NG tube

• Place the end of the tube in water and observe for

bubbling

• Assess the client coughing during administration of the

medication 1 Bubbling or coughing would indicate the possibility of the tube being in the airway, but neither are used to determine placement in the stomach. Forcing air through the NG tube and auscultating the abdomen for the sound of the air is an unreliable method to determine tube placement. Measuring the pH of aspirated stomach contents confirms gastric placement.A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before the nurse gives this medication?

• Bowel sounds
• Oral fluid intake
• Grip strength
• Urine output

4 Potassium chloride should only be administered after adequate urine output (greater than 20 mL/hour for two consecutive hours) has been established. For children the desired urine output is 1 mL/1 kg/1 hour. Impaired ability to excrete potassium via the kidneys can result in hyperkalemia.The nurse reviews the most recent lab results for a client on telemetry who is experiencing premature ventricular beats at 12 per minute. Which lab test would require immediate action by the nurse?

• Calcium 9 mg/dL
• PTT 70 seconds
• Potassium 2.4 mEq/L
• Magnesium 2.4 mg/dL

3 The client low potassium levels is at high risk for ventricular dysrhythmias (normal lab values are 3.5 to 5.0 mEq/L [3.5 - 5 mmol/L]). Premature ventricular contractions may also be caused by low magnesium levels, digoxin and aminophylline toxicity, and hypoxia. Normal values for magnesium are about 1.5 to 2.4 mg/dL (0.75-1.2 mmol/L); normal values for calcium are about 8.5-10.3 mg/dL (2.12 - 2.57 mmol/L)

The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.)

• Peripheral vascular obstruction
• Blood pressure greater than 140 mm Hg systolic
• Irregular heart rate
• Shivering

1, 3, 4

Clients with irregular heart rates, peripheral vascular disease, seizures, tremors, and shivering are not candidates for using an electronic blood pressure machine.A nurse is assessing an 8-month-old infant with a malfunctioning ventriculoperitoneal shunt. Which of these findings should the nurse anticipate the infant might exhibit?

• Lethargy
• Negative Moro reflex
• Irritability
• Sunken anterior fontanelle

3 Irritability is an initial finding for cerebral hypoxia, which would occur from the retained fluid in the brain that results in increased intracranial pressure. Signs of increased intracranial pressure in infants include bulging fontanel, irritability, high- pitched cry, and continual crying when held. Changes in the pulse are variable, e.g., rapid to slow and bounding to feeble. Respirations are more often slow, deep and irregular.The nurse is assessing the functioning of a chest tube drainage system. The nurse should expect which of the following assessment findings? (Select all that apply.)

• Excessive bubbling in the water seal chamber
• Vigorous bubbling in the suction control chamber
• The drainage system is maintained below the client's

chest

• Drainage in the drainage collection chamber
• Occlusive dressing is over the insertion site

3, 4, 5

Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. Gentle (not vigorous) bubbling should be noted in the suction control chamber.Drainage in the system is expected; however, drainage that is more than 70-100 mL/hour is considered excessive and the health care provider should be notified. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.The nurse is preparing to insert a NG tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

• Mark the tube with tape at seven inches
• Mark the tube with tape at 22 inches
• Place the tube at the tip of the nose and measure by

extending the tube to the earlobe and then down to the xiphoid process

• Place the tube at the tip of the nose and measure by

extending the tube to the earlobe and then down to the top of the sternum 3

The nurse prepares to insert an indwelling urinary catheter in a female client. Arrange the following steps in the order the nurse should perform them.

• Insert the catheter 2-3 inches into the urethra
• Put on sterile gloves
• Place the client in a supine position and bend her

knees

• Inflate balloon
• Lubricate the tip of the catheter
• Wipe the client's urinary meatus with sterile solution in

a downward motion

3, 2, 5, 6, 1, 4

The dominant hand needs to remain sterile and any step that requires both hands to complete should be done before the actual insertion of the catheter while maintaining a sterile field. Therefore, lubricating the tip of the catheter should occur before wiping the urinary meatus. Once the nurse has put on sterile gloves, they should open a lubricant package and squirt the lubricant on the tip of the catheter before touching the client with the nurse's non-dominant hand to clean the meatus.A client becomes short of breath and complains of chest pain during his hemodialysis. The nurse suspects an air embolism. What is the priority nursing action?

• Discontinue dialysis and notify the health care provider
• Monitor vital signs every 15 minutes
• Slow down the rate and check the lines for air
• Bolus the client with 250 mL of normal saline

1 Your client patient has an endotracheal tube. You are assessing placement by listening to breath sounds and you notice that they are absent on the client's left side.What does this usually indicate to the nurse?

• The tube may be displaced
• The incorrect tube size was used
• A pneumothorax has occurred and an X-ray should be

ordered

• The tube will readjust once the client is connected to

the ventilator 1 A client is receiving radiation therapy to the left axilla. The

nurse should emphasize:

• Use a warm compress to relieve pain
• Use soap to cleanse area by no deodorant
• Avoid tight clothing around the area
• Avoid moving the left after treatment

3 A bone marrow transplant is being considered for treatment of a client with acute leukemia who has not responded to chemotherapy. In discussing the treatment

with the client, the nurse explains that:

• Hospitalization will be required for several weeks
• Hospitalization is required because the procedure is

painful

• Donor bone marrow cells are transplanted immediately

after an infusion of chemotherapy

• The transplant procedure takes place in a sterile

operating room to minimize the risk for infection 4