1. D. In the patient’s room.
It is best to keep the equipment inside the room for easy access to it when needed and also for infection control measures. The patient in isolation may be immunocompromised or have an infectious disease. Making sure that the thermometer is only on him limits the risk of infection.
2. B. They shuffle their feet while taking small steps
Typical walk of patients with Parkinson’s disease is usually described as shuffling gait, which is due to the degeneration of the basal ganglia. This change in movement is considered part of the extrapyramidal symptoms observed among patients with Parkinson’s disease.
3. D. Left side-lying with the head of the bed elevated 45 degrees
This position helps ensure that the patient is protected from accidental puncture of the surrounding structures in the thoracic cavity. It also exposes the puncture site while helping ensure that the patient has optimal breathing for his condition
4. A, B, D.
Pain during the first stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles.
Slow chest breathing is appropriate during the first stage of labor to promote increased oxygenation as well as relaxation. The woman or her coach can lightly massage the abdomen (effleurage) while using slow chest breathing. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the first stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor. Sipping ice water, while helpful for maintaining hydration, will not be useful as a pain management strategy.
Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid
volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.
The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.
The intravenous infusion is secured appropriately; the sandbag is used to limit movement of the leg. It is not necessary to also secure the uninvolved extremity. The intravenous site should be visible; the nurse should not cover it with tape. The nurse should use an infusion pump with monitoring alarms, and check the infusion rate every hour.
PVCs are characterized by a QRS of longer than 0.10 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted.
Sinus tachycardia is characterized by normal conduction and a regular rhythm, but with a rate exceeding 100 bpm. A P wave precedes each QRS, and the QRS is usually normal.
Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels.
If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the patient warm is important but is not the priority at this time.
Beta-adrenergic medications block the beta-adrenergic receptors. Therefore, the expected outcome of the medication is to decrease the influence of the sympathetic nervous system on the blood vessels in the hands. Beta-adrenergic blockers have no analgesic effects. Increasing blood supply to the affected area is an indirect effect of beta adrenergic blockers. They do not increase monoamine oxidase, which does not play a role in Raynaud’s disease.
The patient demonstrates classic symptoms of DVT, and the nurse should continue to assess the patient. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdominal mass. Patients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg.
Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful “tearing” sensation is typically associated with the sudden release of blood, and the patient may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.
15. A, D, E.
Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The patient should ensure adequate fluid intake of at least 8 glasses per day due to the drying effect of the drug. Antihistamines have no antibacterial action. The effect of antihistamines is prompt, not delayed.
The patient has undergone body changes and permanent loss of verbal communication. He may feel isolated and insecure. The nurse can encourage him to express his feelings and use this information to develop an appropriate plan of care. Discussing the patient’s behavior with his wife may not reveal his feelings. Exploring future plans is not appropriate at this time because more information about the patient’s behavior is needed before proceeding to this level. The nurse can respect the patient’s need for privacy while also encouraging him to express his feelings.
The patient’s age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated patients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.
Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis.
The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the patient is stable.
Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this patient’s height and weight. It is thought that emotional responses can affect overall health; however, not verbalizing one’s feelings is not a contributing factor in postoperative pulmonary complications. The patient’s current activity level and age do not place her at increased risk for complications.
To promote chest tube drainage the drainage system must be lower than the patient’s lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.
It is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a patient that he should anticipate failure. Telling the patient to exercise more self control
does not provide him with support. Taking a vacation to avoid job pressures does not address the issue of fearing he will smoke a cigarette when in a stressful situation.
The Cochrane Library provides systematic reviews of health care interventions and will provide the best resource for evidence for nursing care. CINHAL offers key word searches to published articles in nursing and allied health literature, but not reviews. A nursing textbook has information about nursing care which may include evidence based practices, but textbooks may not have the most up-to-date information. While the policy and procedure manual may be based on evidence-based practices, the most current practices will be found in evidence-based reviews of literature.
The goal of TPN is to meet the patient’s nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of patients. TPN is administered to provide a positive nitrogen balance.
25. C, D, B, A.
A potential complication of receiving TPN is leakage or catheter puncture; notify the physician immediately and prepare for changing of the catheter. If pneumothorax is suspected, position a rolled towel under the patient’s back. If there is drainage at the insertion site, culture the drainage and change the dressing using sterile technique.
Elevated serum concentrations of thyroid hormones and suppressed serum TSH are the features of thyrotoxicosis. Decreased or absent serum TSH is a very accurate indicator of thyrotoxicosis. Increased levels of circulating thyroid hormones cause the feedback mechanism to the brain to suppress TSH secretion.
The elevated blood glucose level indicates hyperglycemia. The hemoglobin is normal. The patient’s cholesterol and LDL levels are both normal. The nurse should determine if there are standing orders for the hyperglycemia or notify the physician.
The patient with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The patient should eat a bedtime snack to help prevent hypoglycemia while sleeping.
29. B, C, E.
The patient with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. Therefore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a patient can use his hands and arms to move the wheelchair, the placement of the back to the patient’s scapula is necessary. This patient cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.
Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the patient from the wheelchair to the toilet or from a standing to a sitting position.