- retinal hemorrhage on funduscopic exam - Inconsistency between injury caregivers explanation

9/25/23, 2:16 PMUWorld Nclex General Critical Thinking and Rationales

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Injury Patterns in Nonaccidental Trauma Signs of Abuse:

• long bone fractures in humerus or femur - Shaken baby syndrome
• linear type immersion burns- Burns in the shape of household items
• frenulum tears & gingival lesions - Repeated injuries in varied stages of healing
• subdural & epidural hematomas- lapsed time between injury and time when care is sought
• retinal hemorrhage on funduscopic exam - Inconsistency between injury & caregiver’s explanation

Room Assignments When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is immunocompromised in a room with a client who has an active or suspected infection.Suicide Clients who articulate long-term personal goals and family milestones are less likely to commit suicide.Bone Healing Bone healingnutrition, adequate circulation depends on multiple factors, including , and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing.Pressure Injuries

Stage 1: Intact skin with nonblanchable redness

Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar Drawing Insulin NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose

vials (mnemonic – : egular before RNR NPH)

1.Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution.

2.Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles.

3.Draw 25 units of NPH insulin, totaling 37 units in one syringe. of NPH into the syringe Any overdraw will necessitate wasting the entire quantity.Transplant During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min).Cardiac Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.

MI:

The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines, oxygen, aspirin, nitroglycerin, morphine) for the client with acute chest pain. Upright positioning improves ventilation and reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers), and place the client on continuous cardiac monitoring.Sickle Cell Amemia The priority intervention is the administration of IV fluidsreduce blood viscosity to and restore perfusion to the areas previously affected by vasoocclusion. Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues. 1 / 3

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retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.

MI:

The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines, oxygen, aspirin, nitroglycerin, morphine) for the client with acute chest pain. Upright positioning improves ventilation and reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers), and place the client on continuous cardiac monitoring.Sickle Cell Amemia The priority intervention is the administration of IV fluidsreduce blood viscosity to and restore perfusion to the areas previously affected by vasoocclusion. Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues.Organ Donation A deceased client who is registered as an organ donor does not need familial consent for organ procurement to proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on the body; deceased clients can still be displayed according to their wishes, including open casket funeral services.Pediatrics A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway, breathing, and circulation support. Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of in children. traumatic death TPN

• Total parenteral nutrition (intravenous nutrition) is high in glucose, which places the client at risk for

hyperglycemia. Signs and symptoms of hyperglycemia include polydipsia, polyuria, headaches, and blurred vision.

• The steps for administering an intermittent enteral feeding include identifying the client, elevating the head of

the bed 30-45 degrees, validating tube placement, assessing bowel function, returning aspirated residual contents to the stomach, flushing before and after feeding with 30 mL of water, and slowly administering prescribed feedings at room temperature (too fast or too cold will cause cramping).Disaster Triage Immediate (red tag): Life-threatening injuries with good prognoses once treated (eg, airway obstruction, open fractures, second- or third-degree burns covering 15%-40% body surface area) Delayed (yellow tag): Injuries requiring treatment within hours (eg, stable abdominal wounds, soft tissue injuries) Minimal (green tag): Injuries requiring treatment within a few days (eg, minor burns or fractures, small lacerations) Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment

• Disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of injury. Clients

with significant alteration in airway, breathing, and circulation who are likely to survive with timely intervention are the first priority.Fall Risk

• Keeping the lights dim increases the risk for falls, particularly when the client is in an unfamiliar

environment. A promotes orientation and helps the client avoid obstacles during ambulation.well-lit room

• Keep bedside commode next to bed to help prevent falls.

Blood Products

• Blood products not be left at room temperature for >30 minutes before should a transfusion is started.

Leaving blood out at room temperature for a prolonged period increases the likelihood of bacterial growth. If the start of the transfusion is delayed, the blood should be returned to the blood bank, where it can be refrigerated at a precise temperature.

• Blood products should not be placed in the unit refrigerator as the temperature cannot be precisely regulated.
• Blood products should be transfused within 4 hours of removal from refrigeration.
• Transfusions should not be interrupted after initiation except in cases of transfusion-related reactions or fluid

overload. In addition, interrupting and restarting transfusions increases the risk for infection. 2 / 3

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environment. A promotes orientation and helps the client avoid obstacles during ambulation.well-lit room

• Keep bedside commode next to bed to help prevent falls.

Blood Products

• Blood products not be left at room temperature for >30 minutes before should a transfusion is started.

Leaving blood out at room temperature for a prolonged period increases the likelihood of bacterial growth. If the start of the transfusion is delayed, the blood should be returned to the blood bank, where it can be refrigerated at a precise temperature.

• Blood products should not be placed in the unit refrigerator as the temperature cannot be precisely regulated.
• Blood products should be transfused within 4 hours of removal from refrigeration.
• Transfusions should not be interrupted after initiation except in cases of transfusion-related reactions or fluid

overload. In addition, interrupting and restarting transfusions increases the risk for infection.Urosepsis Urosepsis is a type of that originates from the urinary tract. A uroseptic client with bloodstream infection chronic kidney disease and hyperkalemia should be treated with IV isotonic fluid boluses and IV broad- spectrum antibiotics. Blood and urine cultures should be obtained. The nurse would question the administration of iodinated contrast to a client with significant kidney disease. ACE inhibitors and angiotensin II receptor blockers should be avoided in clients with hyperkalemia because they impair the excretion of excess potassium and can potentiate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrillation).Ostomy

• Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The

appliance should be changed every 5-10 days.

• The ostomy bag is emptied when it becomes . Leaking and skin irritation may occur if the one-third full

appliance becomes too heavy and pulls away from the skin.

• The client with a colostomy has few dietary restrictions, but the client may be encouraged to decrease intake

of odorous and (eg, beans, onions, broccoli).gas-forming foods Pre-Eclampsia

• multisystem disorder that occurs after the 20th week of pregnancy.
• Preeclampsia is defined as new-onset hypertension (≥140/90 mm Hg) plus proteinuria and/or signs of end-

organ damage after 20 weeks gestation. Although edema is not a diagnostic criterion for preeclampsia, it is a common manifestation of the disease process.

• Clients with preeclampsia are at risk for developing preeclampsia-associated seizure activity as a result of

increased central nervous system irritability. The presence of neurologic manifestations (eg, hyperreflexia, clonus) may indicate worsening preeclampsia and can precede seizure activity. (clonus = the nurse firmly dorsiflexes the foot with 1 hand while supporting the leg and ankle with the other hand. The abnormal finding of positive clonus is identified when are present as the foot is released rhythmic, jerking "beats" of the foot and allowed to fall back into plantar flexion.) Scope of Practice

RN LPN/LVN UAP

• Clinical assessment - Monitoring RN findings- Activities of daily living
• Initial client education - Reinforcing education- Hygiene
• Discharge education - Routine procedures (catheterization) - Linen change
• Clinical judgement - Most medication administrations - Routine, stable vital signs
• Initiating blood transfusion - Ostomy care- Documenting input/output
• Tube patency & enteral feeding - Positioning
• Specific assessments *
• Limited assessments (i.e. lung sounds, bowel sounds, neurovascular checks)

Autism Children with autism spectrum disorder (ASD) respond well to brief, concrete, and developmentally appropriate communication. The nurse can ease anxiety during procedures by involving caregivers and reducing stimulation. Physical touch and eye contact may activate a stress response in children with ASD.Accidental Extubation

• Accidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires

immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved.

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