The charge nurse has received a change-of-shift report on the following clients in labor.
The charge nurse should ask a staff member to first see the client in the
1. First stage of labor who has an oral temperature of 99.7F (37.6 C)
2. First stage of labor whose contractions are occurring every 30 seconds
3. Second stage of labor who has respirations of 26.
4. Second stage of labor whose contractions are lasting for 60 seconds.
The nurse is observing a staff member caring for a client who has chickenpox.
Which of the following actions by the staff member would require the nurse to intervene?
1. Placing the client in a private room with monitored negative air pressure.
2. Placing a box of disposable face shields outside the client's room.
3. Placing an alcohol-based hand rub in the client's room for hand hygiene.
4. Placing a surgical mask on the client during transport out of the client's room.
2. Prepare for transcutaneous pacing.
& 5. Assess the client for angina.
Rationale:
1. Beta Blockers would further decrease HR.
2. External pacing stimulates the ventricles to pump at a set rate.
3. Valsalva maneuver would further decrease HR.
4. Chest compressions are for cardiac arrest.
5. Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Therefore, assessment of angina is appropriate.
1. Encourage the client to reminisce about happy memories.
Rationale:
1. Is correct because it is possible for AD patients to retain long-term memories.
2. Redirect is protocol for dementia. Don't confront, they can't learn.
3. AD is irreversible.
4. In the moderate AD, dementia has already progressed to where the patient needs help with ADL's & planning daily activities. Asking them to plan can frustrate them & cause distress. Structured, pleasant activities that consider the person's likes & interests are the best.
1. "Use your hands and arms to support your body weight."
Rationale:
1. Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands.
2. Is a fall risk.
3. Crutches should be 6 inches in front & 6 inches lateral.
4. Elbow should be bent at a 30 degree angle.
4. "I should expect the blurred vision to resolve after I have received medications for several weeks."
Rationale:
MS causes nerve damage & can result in optic neuritis (Vision loss, blurry vision). In most cases it resolves itself in 4-12 weeks, but medications (steroids can speed up the process & resolve it quicker.
1. MS patients should not exert themselves too much at one time. Space out activities & allow time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but are not the primary treatment.
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already messed up and extra heat can stress the body into overdrive.
Highlight:
"Loss of appetite"
"Abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week."
"Client states, "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach."
"Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air.
Rationale:
Loss of appetite may indicate an underlying medical condition or infection.
The intensity of abdominal pain requires evaluation to determine the cause.
Trauma to the abdomen can cause internal injuries that need to be assessed to ensure no significant damage or complications.
Answer:
Bowel obstruction: Appetite, Bowel Pattern, Gastrointestinal Symptoms.
Appendicitis: Pain level.
Ruptured Spleen: Pain level.
Answer:
•Anemia
•Peritonitis
•Septic Shock
Answer:
Answers:
Indicated:
•Clear liquid diet
•Soapsuds enema
•Abdominal girth measurements
•Abdominal Computed Tomography (CT) scan
NOT indicated:
•Heating pad to abdomen
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
Rationale:
Positive pressure ventilation increases the likelihood of developing stress ulcers and bleeding.
3. 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours.
1. Heart failure who has a productive cough and is anxious.
Rationale: The productive cough (Pink, frothy sputum) indicates pulmonary edema. The patient's anxiety may be caused by decreased perfusion.
1. Assisting a client with atrial fibrillation to shower.
Rationale:
A UAP can perform/assist with hygiene. Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP.
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal.
Answer:
Cow's milk should be introduced at 12 months old. It doesn't provide the necessary nutrients, and the baby can develop iron deficiency.
2. Sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED).
Rationale:
PHI is permitted to be discussed to police when PHI is needed to apprehend the perpetrator of a violent crime, suspect, or fugitive.
4. With heart failure who has a productive cough and is restless.
Rationale:
A productive cough (pink, frothy sputum) is indicative of pulmonary edema which is life threatening. Treatment would be to improve cardiac output by placing client in High-Fowler's, giving them O2, receiving mechanical ventilation, and medications.
2. The client is sleeping but is easily aroused.
1. Closed reduction of a fractured tibia with cast applications 1 hour ago and is reporting that the casted leg feels hot.
Rationale:
Pain, tightness, or a hot feeling can indicate that the cast is on too tight.
2. It is normal to feel nauseous after coming off of anesthesia.
3. Knee pain is expected after knee surgery.
4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in the abdomen after the procedure. This will resolve on its own.
2. Obtain a referral to a physical therapist for the client.
Rationale:
Ataxia is lack of muscle control in the arms and legs, which leads to lack of balance, coordination, and walking. Physical therapy is the area of referral for this type of issue.
1. Thick liquids is for dysphagia.
3. This is always indicated, not just in this circumstance.
4. This can be a tool for patients with expressive aphasia.
1. Breast cancer who had a mastectomy 2 days ago and has had 25mL of drainage from the closed-wound drainage system in the past 12 hours.
Rationale:
This is very little blood in 12 hours for a surgery that was only 2 days ago. The nurse should assess for obstruction of the drainage system which could be life-threatening if not resolved.
2. Who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest.
Rationale:
A petechial rash is indicative of DIC or a fat embolus.
4. Implement droplet precautions.
3. Wearing a protective gown when entering the room of a client with Escherichia coli O157.H7 who is incontinent.
Rationale:
E. coli is contact precautions; wear a gown whenever coming in contact with bodily fluids which is highly likely with an incontinent patient.
1. H.flu is droplet precautions.
2. Strep is droplet, and RSV is contact.
4. They will infect each other, they need private rooms.
1. Uneven stairs.
2. Throw rugs.
4. Dim lighting.
Rationale:
Hemiparesis and confusion are intrinsic factors.
Intrinsic: A characteristic that is inherent to the individual and can not be influenced by behavioral changes.
2. Wear a protective gown when changing the client's bed linens.
4. Place a box of clean gloves outside the client's door.
Rationale:
Impetigo is a highly infectious skin disease spread by direct contact. Contact Precautions include: Gown and gloves. Private closed door and surgical masks are appropriate for airborne and not necessary for contact.
3. Placing tissues and a trash receptacle within the client's reach.
Rationale:
It is important to not leave tissues laying around and to put them in a leak proof bag in the trash.
2. Private room with monitored negative air pressure.
Rationale:
Measles is airborne (MTV) and requires a private room with negative air pressure.
1. Client with hepatitis B (HBV) is eating food brought into the facility by a visitor.
Rationale:
HBV is spread through contact with body fluids including saliva, so it is important to intervene if the patient is eating and possibly sharing food with another person.
1. Computed tomography (CT) scan of the abdomen with intravenous contrast media.
Rationale:
CT's use iodinated contrast which is harmful to the kidneys and therefore is contraindicated in a client with AKI.
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