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Reduction of Risk Potential NCLEX REVIEW ScienceMedicineNursing mgiven2capital Save
NCLEX EXAM PREVIEW
110 terms kandykat1012Preview Reduction of Risk Potential 38 terms Meg_Gates9Preview
Lesson 7: Reduction of Risk Potentia...
45 terms Jacquimartinezoca... Preview Exam C 103 term sum he 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 Eating a steak dinner the night before Recent use of corticosteroids History of a colonoscopy two years ago Family history of colon cancer Recent teeth cleaning at the dentist office Use of naproxen sodium for pain relief Eating a steak dinner the night before Recent use of corticosteroids 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.An 80 year-old client, who is experiencing unintentional weight loss, is admitted with a diagnosis of malnutrition. The nurse understands that which of these lab tests is the most sensitive measure of nutritional status?Serum albumin Urine creatinine Urine protein Serum calcium Serum albumin (WDL is 3.5-5.5)
A client is in the post anesthesia care unit (PACU). The vital signs are now much lower than when the client arrived in the PACU: T = 98 F (36.6 C), apical pulse = 115, respirations = 14, blood pressure = 82/46 mm Hg. The client's skin is cold and clammy. Rank the interventions the nurse should perform from first to last.-Elevate the lower extremities -Assess the surgical dressing -Assess the area dependent to the surgical incision -Increase the intravenous (IV) rate -Reassess vital signs The client is exhibiting signs of hypovolemia. The first intervention should be to increase the IV rate to maintain circulatory volume. The nurse should then elevate the lower extremities to bring fluid from the lower body to the core, assess the surgical dressing for bleeding (as well as any sites dependent to the incision), and then reassess the vital signs to evaluate the interventions.The nurse is reviewing information about using a plastic thoracolumbosacral orthotic (TLSO) with a teen who was recently diagnosed with scoliosis. Which statement made by the client indicates the need for further education?"I will remove the brace when I shower or go swimming." "I should lie down in bed to remove the brace." "I should not lift objects over 10 pounds." "I should wear a sweatshirt under the orthotic to help protect my skin." "I should wear a sweatshirt under the orthotic to help protect my skin." The TLSO is a custom molded brace prescribed to give support to the spinal column from the sixth thoracic vertebra to the sacrum. Clients are advised to wear only a tight fitting t-shirt under the brace to protect the skin and absorb sweat.A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is the priority?Check the skin around bony prominences Inspect the pin sites for signs of drainage Perform a bilateral neurovascular check of lower extremities Auscultate the lungs for bilateral atelectasis Perform a bilateral neurovascular check of lower extremities Promotion of neurovascular integrity is the most important aspect of care for this client, which is why the nurse would want to regularly assess the pedal pulse, color, temperature, sensation, and capillary refill of the involved extremity. Russell's traction is Buck's traction with a sling under the knee. This is a skin traction and not skeletal traction with pins; therefore, the pin sites are an inappropriate focus.The preoperative nurse completes a health history on a client scheduled for a general anesthetic. Which of the following statements made by the client may indicate a risk for serious complications? (Select all that apply.) "My lips have been itching ever since I blew up balloons for my daughter this morning." I am kind of sore all over; I get muscle cramps a lot." "My uncle got a fever and died unexpectedly during surgery." "I am scared of waking up during anesthesia." "My lips have been itching ever since I blew up balloons for my daughter this morning." I am kind of sore all over; I get muscle cramps a lot." "My uncle got a fever and died unexpectedly during surgery."
The nurse is preparing a client for an intravenous pyelogram (IVP). The nurse should take which action to adequately prepare the client?Restrict the client's fluid intake four hours prior to the examination Inform the client that only one x-ray of the abdomen is necessary Administer a laxative to the client the evening before and an enema the morning of the test Instruct the client to maintain a regular diet the day prior to the examination Administer a laxative to the client the evening before and an enema the morning of the test Bowel prep is important prior to this procedure because a cleaned out GI tract allows greater visualization of the bladder and ureters. The client is usually NPO 8 to 12 hours before the test. After the dye is injected intravenously, x-rays are taken of the kidneys, ureters, and bladder at several intervals (typically at 0, 5, 10 and 20 minutes).The nurse provides information to a client who is scheduled for a radiofrequency catheter ablation to control atrial fibrillation (AF). Which statement indicates the client correctly understands information about the procedure?"I'm a little concerned about having open heart surgery." "I am so glad I won't have to take that blood thinning medication any longer." "A cardioversion of my heart will be performed during the procedure." "I may need another ablation if this one doesn't work." "I may need another ablation if this one doesn't work." The postpartum nurse is caring for a couplet four hours after a vaginal delivery with a partial abruption of the placenta prior to delivery. The nurse would immediately notify the health care provider (HCP) based on which of the following data?Infant is Rh positive Maternal urine output is 280 mL/8 hours D-dimer test result is increased Hemoglobin is 10.4 g/dL (6.45 mmol/L) D-dimer test result is increased An increased D-dimer test following a partial abruption raises the concern of disseminated intravascular coagulation; the HCP should be notified right away. The urine output is a bit low; the nurse should continue to monitor this. Infant Rh+ would need to be addressed if the mother is Rh (-) but there's nothing to indicate the mother is Rh negative. Even so, this is not an immediate concern since this drug can be given within 72 hours following birth. The hemoglobin is adequate for a postpartum client, especially one who experienced increased bleeding due to an abruption. A hemoglobin less than 8 g/dL (4.96 mmol/L) might require a transfusion, but you don't know if this lab value is stable or decreasing.A nurse is providing care to a 17 year-old client in the post anesthesia care unit (PACU) after an emergency appendectomy. Which finding is an early indication that there is diminished oxygenation?Cyanosis of the lips Pulse oximeter reading of 92% Abnormal breath sounds Increasing pulse rate Increasing pulse rate
The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate?Restrict oral fluid intake post-procedure Ibuprofen (Motrin) 800 mg by mouth PRN for pain post-procedure Metformin (Glucophage) 500 mg by mouth pre-procedure Monitor serum creatinine levels pre- and post-procedure Monitor serum creatinine levels pre- and post-procedure Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN.The nurse is caring for a client following a thyroidectomy. The laboratory results indicate hypocalcemia, probably related to parathyroid gland damage when the thyroid gland was removed. Identify the part of the body the nurse should check to assess Chvostek's sign.The nurse assesses a 70 year-old male's laboratory results during a routine clinic visit. Which result would indicate a need for information and education?LDL Cholesterol 130 mg/dL (3.37 mmol/L) Serum glucose 90 mg/dL (5 mmol/L) RBC 5.0 million/mm3 ( 5 x 1012/L) Serum albumin 2.5 g/dL (25 g/L) Serum albumin 2.5 g/dL (25 g/L) Plasma protein concentrations can be affected by many diseases common in older adults. Hypoalbuminemia (less than 3 g/dL [or 30 g/L]) is an early indicator of increased risk of death and is usually caused by acute and chronic inflammatory responses; it can also be caused by nephrotic syndrome, hepatic cirrhosis, heart failure, and malnutrition. The health care provider needs to treat the underlying causes of the low albumin.The client also needs a dietary consult to learn about increasing his dietary intake of protein. Socioeconomic factors, especially financial factors, may need to be addressed to help the client comply with the recommendation.A client newly diagnosed with type 1 diabetes mellitus asks: "What is the purpose of the test that measures that funny glucose value over time?" Which response best answers the client's question?"The oxygen carrying capacity of your red cells is reflected in this type of test." "It indicates the presence of glucose attaching itself to red cells over the past two weeks." "Called glycolsolated hemoglobin, it is the average blood glucose for the past two to three months." "It compares the risk for cardiac complications with the risk for cerebral infarctions associated with sugar levels." "Called glycolsolated hemoglobin, it is the average blood glucose for the past two to three months."
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