NCLEX RN Mastery with rationale

NCLEX RN Mastery with rationale

The nurse is caring for a client with suspected meningitis after a lumbar puncture was performed.Which of the following indicates an expected outcome after the procedure?

• The client has a small amount of bloody drainage at the insertion site.
• The client has pupils of unequal size.
• The client has a small hematoma at the insertion site.
• The client reports a HA with mild dizziness - The client reports a HA with mild dizziness

(HA is a mild but common complication that occurs in 10-30% of clients in the hours following the procedure, and maybe be accompanied by dizziness, N/V, tinnitus, and visual changes)

What is a lumbar puncture procedure used to diagnose? - ~ Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis ~ Bleeding around the brain (subarachnoid hemorrhage) ~ Certain cancers involving the brain or spinal cord ~ Certain inflammatory conditions of the nervous system, such as multiple sclerosis and Guillain-Barre syndrome

Complications of lumbar puncture (spinal tap)? - infection, bleeding, sudural hematoma formation, and cerebral herniation

What is a lumbar puncture and what is the patient's positioning? - During a lumbar puncture (spinal tap) procedure, you typically lie on your side with your knees drawn up to your chest.Then a needle is inserted into your spinal canal — in your lower back — to collect cerebrospinal fluid for testing.

The nurse is supervising care of a graduate nurse performing gastric lavage on a client with Acetaminophen overdose. The nurse should intervene if which action is observed?

• Iced solution is instilled to promote vasoconstriction
• Changes in VS and LOC are monitored
• The client is placed in side-lying Trendelenburg
• A large bore (38 F) tube is inserted for instillation of lavage fluid - A. Iced solution is instilled

to promote vasoconstriction (A warm solutiom should be instilled to prevent irritation of the vagal nerve as well as dangerous temp changes in client)

What is Gastric Lavage? Why is it performed? - ~ A procedure that uses a nasogastric tube to "pump" the stomach, rinsing the gastric organ out with another fluid. An NG tube is inserted, instilled with fluid, and then the contents are aspirated, either intermittently or continuously.~ Used in clients after a drug overdose or in clients with GI bleeding to clean the GI tract of clots and residue in preparation for endoscopy

How do you know if an NG tube is placed correctly? - ~ Most tubes have a radiopaque marker or strip at the distal end to help confirm the tubes placement. ~ Aspirate for stomach contents and test the pH for secondary confirmation.

What is the typical gastric fluid appearance? - ~ Grassy green, clear and colorless with mucous shreds, or brown ~ the pH is less than or equal to 5.0

How do you determine how long an NG tube must be to reach the stomach? - Hold the end of the tube at the tip of the patient's nose. Extend the tube to the patient's earlobe and then to the xiphoid process.

What are the diagnostic and therapeutic applications of an NG tube? - ~ assessing and treating upper GI bleeding ~ collecting gastric contents of analysis ~ peforming gastric lavage ~ aspirating gastric secretions ~ administering medication and nutrients

The nurse is caring for a post-op client with a BUN of 60 mg/dL and a creatinine level of 3.2 mg/dL. The provider has ordered an infusion of 1 L of 0.9% NaCl with 40 mEq KCl to be administered over 2 hours. Which of the following is a priority nursing action?

• Assess the client's urinary output.
• Administer the IV fluid replacement.
• Question the infusion of 0.9% NaCl with 40 mEq KCl.
• Encourage the intake of protein rich foods in diet. - ~ The order for 1 L of 0.9% NaCl with 40

mEq KCl should be questioned. Increased blood urea nitrogen and creatinine indicate renal dysfunction. Elevated BUN can indicate dehydration, but the creatinine also indicates renal problems.~ Fluids should be monitored as the kidneys may not efficiently clear excess fluids and maintain fluid balance.~ The kidneys are responsible for fluid and electrolyte regulation Potassium is excreted by the kidneys, and if it is not cleared from the body, excess potassium will lead to cardiac issues.

Should patient's with renal insuffiency be encouraged to eat a protein rich diet? - No. Urea products from protein are cleared by the kidney and could build up with renal insufficiency, so encouraging protein intake is not a good intervention until BUN and creatinine labs improve.

The nurse is caring for a client following a TURP procedure. Which of the following findings most concerns the nurse?

• HR of 116 bpm
• Small blood clots in the urine
• Urine output of 20 mL/hour
• Urinary retention - Heart rate of 116 bpm, could be a sign of infection. This symptom, along

with fever, should be monitored for and reported after surgery. Clients who undergo a TURP are at risk for both local and systemic complications.

What is a TURP and what's it for? - A transurethral resection of the prostate involves surgical insertion of a thin instrument called a resectoscope through the urethra. Some of the prostate

tissue surrounding the urethra is trimmed away enlarging the lumen of the urinary channel to relieve symptoms of BPH.

What's the procedure after a TURP? - ~ The client is placed on continuous bladder irrigation with a triple lumen catheter. Some blood clots and pink urine will be expected. Bright red bleeding in the urine should be reported.~ The urinary catheter should be discontinued as soon as possible. Some clients report transient urinary retention.

Systemic complications from a TURP? - TURP syndrome. Symptoms related to fluid overload or fluid shifts, hyponatremia or electrolyte imbalances, bleeding, or signs of infections should be reported.

The nurse is supervising a new nurse orientee while providing care to a client with a central venous catheter. The nurse should intervene when the new nurse is observed performing which of the following actions?

• Wearing non-sterile gloves when connecting IV tubing to the central venous catheter
• Changing the clear catheter dressing after 72 hours.
• Withdrawing venous blood directly from the catheter for a laboratory test of serum potassium.
• Flushing the unused catheter ports with a 3 mL luer lock syringe containing normal saline. -

Flushing the unused catheter ports with a 3 mL luer lock syringe containing normal saline. Only 10 mL syringes should be used to minimize pressureon the catheter.

What is a central venous catheter and what is it used for? - A CVC or Central line is a catheter inserted into a large vein- like the femoral, subclavian, jugular, or axillary vein, with the tip placed close to the heart.~ For the purpose of administering dialysis, supplemental fluids, parenteral nutrition, medication, obtaining blood for testing, and allows monitoring of central venous pressure.~. Use in critically ill and chronically ill patients over the course of several weeks or months.

The nurse is caring for a client weighing178 lbs. who is receiving dobutamine IV at 0.7 mcg/kg/min. Dobutamine is supplied in a concentration of 20 mg/ 20 mL. The nurse finds that the IV pump is infusing at 20 mL/hour. Of the following, which is the priority nursing action?

• Assess the HR and BP
• Discontinue the dobutamine infusion
• Begin an infusion of normal saline to support blood pressure
• Notify the health care provider immediately. - Discontinue the dobutamine infusion.

~ To calculate the appropriate dosage, perform the lbsfollowing steps:

- Covert the client's weight to kg: 178 lbs/2.2=80.9 kg

• Multiply the client's weight by the drug concentration: 81 kg x 0.7 mcg/kg/min = 56.7 mcg/min
• Multiply this by the concentration and convert the units to mL/hour: 56.7 mcg/min x 20

mL/20,000 mcg x 60 = 3.4 mL/hour ~ The client is receiveing an infusion at 3.4 mL/hour, but the pump is running at 20 mL/hr ~ the pump is infusing at approximately 6x the right dose, which will cause ventricular tachycardia and hypotension.

The nurse is reviewing new orders of a client with CHF. Which of the following orders would the nurse clarify with the health care provider?

• Metoprolol 100 mg PO BID
• 0.9% NS IV at 75 mL/hour
• Furosemide 20 mg PO BID
• Carvedilol 12.5 mg PO BID - IV fluids may exacerbate CHF and should be questioned.

What are goals in treatment of CHF? - Reducing hypertension, increasing the contractility of the heart, and reducing excess fluids in the body.

What medications decrease the HR and cause vasodilation, and lowers BP? - Beta blockers

How are diuretics therapeutic in treating CHF? - lowers the load on the heart by decreasing BP

The nurse is caring for a client receiving IV Lasix for acute renal failure. Which of the following findings should the nurse report to the healthcare provider?

• Dependent sacral edema
• 24 hour urine output of 2500 mL
• Serum Potassium level of 5.1 mEq/dL
• Arterial blood pH of 7.50 - Arterial blood pH of 7.0.

~ Contraction alkalosis occurs when fluids are removed (as with diuretic) but bicarbonate remains. As fluid volume is lost, the release of angiotensin and aldosterone will be stimulated, which can leas to an increase in HCO3- absorption potassium secretion.

The nurse is preapring to administer an intermittent bolus feeding to a client with a NG tube.When testing the pH of sampled fluid to confirm placement of the tube, the result is 7.7. The

nurse's next action should be:

• Remove the gastric residual, measure the volume, then reinstill the contents
• Instill 30 mL of air to ensure the tube isn't lodged against the stomach wall
• Call the provider with the results if the pH test and order an x-ray
• Attach the feeding syringe and instill the prescribed volume of formula slowly - Call the

provider with the results of the pH and order a x-ray.~ With pH results of 7, this indicates possible displacement of the tube into the lungs.

How do you test the pH of removed gastric content? When do you test it? - ~ Always tested before administration of an intermittent feeding.~ To do this, place a drop of the fluid on a piece of pH paper and wait 30 seconds, and then compare the color with the manufacturer's chart ~ The pH of gastric contents should be less than 5.5 and be green, tan, or white. If the patient takes an acid-inhibiting med, less than 6.0 is normal.~ the fluid in the small intestine is yellowish or brown-green and thicker, and the pH is 6 or higher

When do you check gastric residual? - After checking the pH. The entire contents are removed and measured before every intermittent feeding or every 4-6 hours for continuous feeding to monitor for delayed gastric emptying. Unless the volume is great, it is reinstilled