Lesson 7: Reduction of Risk Potential

Lesson 7: Reduction of Risk Potential

Leave the first rating Students also studied Terms in this set (45) Science MedicineNursing Save NCLEX LPN Reduction of Risk Poten...108 terms janay_hillmanPreview Reduction of Risk Potential NCLEX R...19 terms mgiven2capital Preview ATI comprehensive predictor STUDY...198 terms h_trtPreview Fixed - 20 terms som A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect?

• Level of consciousness (LOC)
• Injuries to the extremities
• Pulse and blood pressure
• Amount of intravenous fluid infused

Correct Answer: A

Rationale: Cerebral blood flow undergoes a significant increase during seizure

activity with a depletion of 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 (LOC) after a seizure. Although the other information is also important, LOC is the priority data for the nurse to collect after a seizure.The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure?

• Time of the client's last meal
• BUN and creatinine level
• Amount of urine output
• History of allergies

Correct Answer: D

Rationale: An IVP requires the injection of a dye. Although all of the information is important for the nurse to obtain and review, dye or contrast media used during a diagnostic test can cause an allergic reaction or anaphylaxis. Therefore, it is most important for the nurse to review any allergies with the client, especially any reaction to previous tests that use a dye or contrast media.An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client?

• Push fluids for the next eight hours.
• Administer a nebulizer treatment.
• Encourage client to ambulate frequently.
• Spray the oropharynx with saline.

Correct Answer: B

Rationale: Spraying the throat with saline may cause irritation and coughing and could reduce oxygenation. The specimen needs to come from deep in the lungs, not from the nose or mouth. Increasing fluid intake for eight hours will not be sufficient in liquefying secretions. Although ambulation will help with mucociliary action and ability to expectorate secretion, the most helpful intervention is to administer a nebulizer treatment with sterile water or hypertonic saline that will thin secretions and facilitate expectoration.

A client is receiving heparin and warfarin after total hip replacement surgery. Lab results show an international normalized ratio (INR) of 5.5. Which priority action should the nurse take?

• Administer protamine sulfate.
• Hold the next dose of warfarin.
• Notify the health care provider (HCP).
• Monitor for bruising or bleeding.

Correct Answer: C

Rationale: The INR lab test is used to evaluate the therapeutic effectiveness of warfarin, an anticoagulant. The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk for bleeding and the nurse should notify the HCP immediately. The nurse should also monitor the client closely and hold the warfarin until the nurse has communicated with the HCP. Protamine sulfate is the antidote for heparin, not warfarin, and the therapeutic range for heparin is measured with a partial thromboplastin time (PTT), not an INR.A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At 11:00 am, the child has a

temperature of 98.2⁰ F (36.7⁰ C). At 1:00 pm, the child's

parent reports to the nurse that the child feels very warm to touch. What should the nurse do first?

• Offer the child cold oral fluids.
• Administer prescribed acetaminophen.
• Take the child's temperature.
• Reassure the parent that this is normal.

Correct Answer: C

Rationale: The parent's report of warm skin is a subjective sign and the nurse

should first obtain a temperature reading to confirm that the client's temperature is truly elevated. A low-grade fever (99 to 101⁰ F or 37.2 to 38.3⁰ C) is common after surgery. Usually, the health care provider (HCP) is contacted if the temperature is higher than 101.5⁰ F (38.6⁰ C). After the nurse has validated and evaluated the client's temperature, the nurse should implement the other actions.The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client's history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period?

• Estrogen replacement therapy for the past three years
• History of acute hepatitis A
• Past hypersensitivity to heparin
• Family history of uterine cancer

Correct Answer: A

Rationale: Post-menopausal women using hormone replacement therapy have a

higher risk of DVT and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT. The other information in the client's history is unremarkable for postoperative complications such as DVT.The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.)

• Secretions
• Bronchospasms
• Kinked tubing
• Partial or total extubation
• Ventilator malfunction

Correct Answers: A, B, C

Rationale: High-pressure alarms are usually caused by something preventing or

blocking air from being delivered by the ventilator to the lungs. Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm. Total or partial extubation would cause a low-pressure alarm due to air escaping from the closed circuit and ventilator malfunction would produce a machine inoperable or similar alarm.

The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.)

• Recent teeth cleaning at the dentist office
• Use of naproxen sodium for pain relief
• Recent use of corticosteroids
• Family history of colon cancer
• Eating a steak dinner the night before
• History of a colonoscopy two years ago

Correct Answers: A, B, C, E,

Rationale: Occult blood (OB) testing of the stool is used for colorectal cancer

screening or to detect occult blood from other causes such as gastric or duodenal ulcers, diverticulosis or gastrointestinal (GI) bleeding. Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve).Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin.A family history of colon cancer may put the client at an increased risk for developing colon cancer but would not directly affect the OB test. A recent colonoscopy might affect the stool sample but since the colonoscopy was two years ago, it would not affect the current results.A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department?

• Keep the client on bedrest.
• Insert a temporary urinary catheter.
• Hold all of the client's medications.
• Confirm that a signed consent is in the chart.

Correct Answer: D

Rationale: A signed consent is required due to the fact that contrast media will be used. Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test.Keeping the client on bedrest, inserting a catheter or holding medications are usually not required and could actually cause harm to the client.An 80-year-old client with type 2 diabetes mellitus is admitted to the emergency department with worsening confusion and decreased level of consciousness. Which of these findings is most important for the nurse to report to the health care provider?

• Blood glucose of 380 mg/dL
• Urine output greater than 100 mL/hour
• Serum osmolarity of 355 mOsm/L
• Arterial blood pH of 7.36

Correct Answer: C

Rationale: The nurse must be able to differentiate between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) and their correlating laboratory values. HHS occurs more often in type 2 diabetics than type 1 diabetics and is more likely in older adult clients. Many older adults have contributing risk factors such as diuretic use, impaired thirst mechanism, dehydration and inadequate oral fluid intake. HHS is characterized by elevated blood sugar level (often > 600), blood osmolarity > 320 to 350 (normal = 270 to 300), polyuria and normal blood pH (absence of ketosis and acidosis). Hyperosmolarity and severe cellular dehydration will cause central nervous system problems, from worsening mental status to seizures, coma and death. The first priority for this client is fluid replacement to correct the severe dehydration.

The nurse is developing a plan of care for a client with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse include in the plan?(Select all that apply.)

• Instruct the client to engage in high-intensity aerobic

exercise to increase activity tolerance.

• Schedule the client for an annual influenza vaccination.
• Instruct the client on the pursed-lip breathing

technique to reduce carbon dioxide (CO2) retention.

• Provide high-protein, high-calorie meals to help

maintain adequate nutrition.

• Educate the client about relaxation techniques to help

with their anxiety.

Correct Answer: B, C, D, E

Rationale: Diaphragmatic (abdominal) and pursed-lip breathing help manage

dyspneic episodes that occur with COPD. Breathing through pursed lips creates mild resistance, which prolongs exhalation and increases airway pressure. This technique delays airway compression and reduces air trapping prevalent with COPD. Clients with COPD tend to become anxious during acute dyspneic episodes. The nurse will help the client manage dyspneic episodes and panic attacks through the use of progressive relaxation, hypnosis therapy and biofeedback. For some clients, anxiolytics may be needed. Pneumonia is a common complication of COPD and the client should receive the yearly influenza vaccine. Clients with COPD tend to feel too full to eat, and have poor appetite and meal-related dyspnea. The work of breathing raises the client's calorie and protein needs, which can lead to protein-calorie malnutrition. It is important to urge the client to eat small, frequent meals of high-calorie, high-protein foods.Exercise for conditioning and pulmonary rehabilitation can improve function and activity tolerance in clients with COPD. Each client's exercise program should be personalized to the client's limitations. The simplest plan is to have the client walk daily at a self-paced rate, until symptoms limit further walking. High-intensity aerobic exercise would not be appropriate for the client with COPD.The nurse is caring for a client with orders for oxygen (O2) per nasal cannula at 5 L/min. Approximately what fraction of inspired oxygen (FiO2) is the client receiving?

A. 36%

B. 40%

C. 28%

D. 21%

Correct Answer: B

Rationale: Room air has an O2 concentration of approximately 21%. Supplemental

O2 therapy is prescribed when the client's oxygenation needs are not met by room air. A nasal cannula can provide O2 at 0.5 to 6 L/min, corresponding to a FiO2 range of 25% to 40%. At 5 L/min, the client would be receiving approximately 40% O2. If the client's oxygenation needs are still not met, the O2 delivery system should be changed from a low-flow system like a nasal cannula to a high-flow system such as a nonrebreather mask.~ FiO2 DELIVERED Nasal Cannula 24%-40% FiO2 at 1-6 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 24% at 1 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 28% at 2 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 32% at 3 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 36% at 4 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 40% at 5 L/min ~FiO2 DELIVERED Nasal Cannula ≈ 44% at 6 L/min