NURS 258 FINAL

A nurse is observing the closed chest drainage system of a client who is 24 hours post thoracotomy. The
nurse notes slow, steady bubbling in the suction control chamber. What action should the nurse take?
- Continue to monitor the client’s respiratory status
- (slow steady bubbling in the suction control chamber is an expected finding)

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the
prostate (TURP). The nurse notes that the patients indwelling catheter has not drained in the past hour.
What action would the nurse take first?
- Check the tubing for kinks
- (Use the least restrictive intervention first)

A nurse in monitoring a client who was admitted with a severe burn injury and is receiving IV fluid
resuscitation therapy. The nurse should identify a decrease in which of the following findings as an
indication of adequate fluid replacement?
- Heart rate
- (When a clients circulating fluid volume is low, the heart rate increases to maintain adequate
blood pressure. Therefore the nurse should identify a decrease in heart rate as in indication of
adequate fluid replacement.

A nurse in caring for a client who has cancer and a new prescription for odansetron tp treat chemotherapy
induced nausea. Which of the following adverse effects should the nurse monitor?
- Headache
- (This is a common adverse effect of this medication)

A nurse is caring for a client who has active pulmonary TB and is to be started on intravenous rifampin
therapy. The nurse should instruct the client that this medication can cause which of the following adverse
effects?
- Body secretions turning a red orange color
- (Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine,
stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.)

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia.
Which of the following is the priority action for the nurse to take?
- Perform a neurovascular assessment
- (The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a
neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at
the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can
be remembered by the acronym "C-M-S check.")

A nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. The client reports a
tingling sensation in the hands, the soles of the feet and around the lips. For which of the following should
the nurse assess the client?
- Chvostek’s sign
- The nurse should suspect that the client has hypocalcemia, a possible complication following
subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the
hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after
surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and
in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial
muscles, suggesting neuromuscular excitability due to hypocalcemia.

A nurse is caring for a client who was admitted with bleeding esophageal varices and has a
esophagogastric balloon Tamponade with sengstaken-blakeore tube to control the bleeding. What action
should the nurse take?
- Provide frequent oral and nares care
- A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert,
the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert,
gentle suctioning of the oral cavity and nares might be required to remove secretions.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear
drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?
- Test the drainage for glucose
- This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in
clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid
coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments,
the client reports fatigue. Which of the following actions should the nurse take?
- Check the results of the clients most recent CBC
- The client might have anemia as a result of myelosuppression (bone marrow suppression) from
the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and
the provider might have to delay further chemotherapy until her blood counts are higher.

A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the
nurse several questions about what the provider might be planning to do. Which of the following nursing
responses should the nurse make?
- Encourage the client to write down questions to ask the provider.
- The nurse does not know the answers to the client's questions, so helping the client to prepare
questions for the provider addresses the client's needs.

A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from
the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?
- Test tests help to determine the degree of damage to the heart tissues
- Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the
degree of damage to the myocardium. The enzymes most commonly measured are CPK and
troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or
more after the onset of manifestations for the test to become abnormal and up to 24 hr for the
level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood
tests must be taken from the client to document and evaluate enzyme levels.

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured
mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following
actions is the priority for the nurse to take?
- Prevent aspiration
- When using the airway, breathing, circulation approach to client care, the nurse should determine
that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired
together, aspiration of emesis is a possibility. Therefore, the client should be given medication for
nausea, and wire cutters should be kept at the bedside in case of vomiting.

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV. The
client asks the nurse how long it will take for the heparin to dissolve a clot. Which of the following
responses should the nurse give?
- Heparin does not dissolve a clot is prevents new ones from forming
- This statement accurately answers the client's question.

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
manifestations should the nurse monitor?
- Weakness
- Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory
distress or predispose the client to respiratory infections.

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse
expect?
- increased heart rate
- increased blood pressure
- Increased RR
 - Increased heart rate is correct. The nurse should expect the client who has fluid volume excess
to have tachycardia and increased cardiac contractility in response to the excess fluid.

Increased blood pressure is correct. The nurse should expect the client who has fluid volume
excess to have increased blood pressure and bounding pulse in response to the excess fluid.

Increased respiratory rate is correct. The nurse should expect the client who has fluid volume
excess to have increase in respiratory rate and moist crackles heard in lungs

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse
identify as an indication of infection at the pin sites?
- Fever
- Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor,
loose pins, and tenting of the skin around the pin sites.

A nurse is caring for a client who has chemotherapy induced peripheral neuropathy. The nurse should
expect the client to report having of the following symptoms?
- Tingling in the extremities
- Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves.
It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from
chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness,
tingling, burning, or a loss of feeling in the extremities.

A nurse is assessing a client who has a long history of smoking and suspected of having laryngeal
cancer. The nurse should anticipate that the client will report that her earliest manifestation was?
- Hoarseness
- Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest
manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords
during speech. The voice may sound harsh and lower in pitch than normal.

A nurse is instructing a client who is newly diagnosed with pulmonary TB about the use of antitubercular
medications. Which of the following information should the nurse include in the teaching?
- A typical course of treatment involves 6-9 months of consistent medication use
- Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active
TB is usually treated with the simultaneous administration of a combination of medications to
which the organisms are susceptible. Such therapy is continued until the disease is controlled. A
6- to 9-month regimen consisting of two, and often four, different medications is used. The client
should not drink alcohol during this time.

A nurse is craing for a client who is 1 day post op following a transphenoidal hypophysectomy. While
assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing.
Which of the following should be the nurse’s initial action.
- Check the drainage for glucose
- A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage
from the nose is a sign that this complication has occurred. The first action the nurse should take
using the nursing process is to assess the drainage for the presence of glucose, which would
indicate that the drainage is CSF.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss.
The client reports chills and back pain and the clients BP is 80/64. What action should the nurse take
first?
- Stop the infusion of blood
- This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk
to this client is injury from receiving additional blood; therefore, the first action the nurse should
take is to stop the infusion of blood.
A nurse in the ED is caring for a clinet who has a sucking chest wound resulting from a gunshot. The BP
is 100/60, pulse is 118/mon and RR of 40. What is the priority for the nurse?
- Administer oxygen via nasal cannula
- The client has an increased respiratory rate and heart rate, indicating that she is having
respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a
hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the
oxygen available to the tissues.

A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine the nurse
should explain to the clinet that which medication is for the following indications?
- Controlling emesis
- Diminishing anxiety
- Reduceing amount of narcotics needed
- Drying secretions
- Controlling emesis is correct. Hydroxyzine is an effective antiemetic that may be used to
control nausea and vomiting in preoperative and postoperative clients.

Diminishing anxiety is correct. Hydroxyzine is an effective antianxiety agent that may be used
to diminish anxiety in surgical clients, as well as in clients who have moderate anxiety.

Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine potentiates
the actions of narcotic pain medications; therefore, narcotic requirements may be significantly
reduced.
- Drying secretions is correct. Hydroxyzine, an antihistamine, commonly causes drying of the
oral mucous membranes.
A nurse is assessing a client who is receiving IV vancomycin. The nurse notes flushing of the neck and
tachycardia. Which of the following actions should the nurse make?
- Decrease the infusion rate of the IV
- This client is experiencing Red man syndrome, which includes a flushing of the neck, face, upper
body, arms and back along with tachycardia, hypotension and urticaria. This can lead to an
anaphylactic reaction if the IV infusion rate is not slowed down to run greater than 1 hour.

A nurse is caring for a clinet who has a new diagnosis of urolithiasis. Which of the following should the
nurse identify as an associated risk factor?
- Family history
- Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a
client who has kidney stones for familial tendencies toward stone formation.

- "Warfarin takes several days to work, so the IV heparin will be used until the warfarin
reaches a therapeutic level."
- Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and
help prevent thrombosis formation in the blood vessels. However, these medications work in
different ways to achieve therapeutic coagulation and must be given together until therapeutic
levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days.
When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

- Check the catheter tubing for kinks or twisting.

- The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can
affect the flow of urine causing pooling in the tubing that could backflow into the bladder.
 - Pantoprazole 80 mg IV bolus twice daily
- The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease
gastric acid production, which ultimately decrease pancreatic secretions.

- Turn the client's head to the side.

- The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.

- Massaging her legs

- Massaging an extremity that has a blood clot can cause it to detach and become an embolus.
The use of sequential compression devices and antiembolic stockings and therapeutic
anticoagulation can help prevent this postoperative complication.

- Movement of the trachea toward the unaffected side

- A chest tube inserted for a spontaneous pneumothorax may result in the development of a
tension pneumothorax, a medical emergency. This results from air in the pleural space
compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment
of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of
tension pneumothorax and should be reported to the provider immediately.

- Apply to intact skin is correct. The nurse should apply cream over intact skin to reduce the risk for
systemic toxicity. The nurse should wear gloves while applying the cream to reduce the risk of absorbing
the anesthetic.

Apply the medication an hour before the procedure begins is correct. The nurse should allow 30 min
to 1 hr for the topical analgesic to take effect.

Cleanse the skin prior to procedure is correct. Apply the topical analgesic to clean skin to increase
absorption.

Use a visual pain rating scale to evaluate effectiveness of the treatment is correct. A child’s
response and understanding of pain depends on the child’s age and stage of development. A preschooler
might be unable to describe pain due to a limited vocabulary. Use a visual scale (FACES or OUCHER
Scale) with faces or colors to assess evaluate the effectiveness of the treatment.
- "I will limit my alcohol intake."
- A client who has gout should limit alcohol consumption, which is known to cause a gouty attack
by inhibiting excretion of uric acid and leading to its buildup. However, clients should be
encouraged to increase their fluid intake to help prevent formation of urinary stones.

- Regular insulin
- Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset
of action of less than 30 min. This is the insulin that is most appropriate in emergency situations
of severe hyperglycemia or diabetic ketoacidosis.

- Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- The nurse should instruct the client to avoid activities that increase intraocular pressure.
Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb)
for 1 week following surgery.

- Hemolytic
- A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign
blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy
them in a process known as hemolysis. The destroyed cells are excreted by the kidneys
(hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in
acute renal injury, disseminated intravascular coagulation, and circulatory collapse.

- Alendronate
- The client must take alendronate first thing in the morning on an empty stomach and wait at least
30 minutes before eating, drinking, or taking other medications.

- Pinch the tube prior to attaching the medication syringe.

- After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to
prevent distention from air entering the tube.

- WBC 2300/mm3
- This WBC finding is below the expected reference range. Chemotherapy treatment can cause
leukopenia; the nurse should report this finding to the provider and implement precautions to
protect the client from infection.
- "I need something for the pain in my eye. I can't stand it.
- Following cataract surgery, the client should expect only mild pain and should immediately report
any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery
might indicate increased intraocular pressure or hemorrhage.

- "Monitor for muscle pain."

- This medication can cause rhabdomyolysis. The client should monitor and report muscle pain.

- Lower the height of the solution container.

- If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by
lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving
the catheter in place. The nurse should then continue administering the enema at a slower rate
once the cramping has passed.

- Offer the child a choice of taking the medication with juice or water.
- While taking the medicine is not a choice, the child can decide what kind of fluid to take with the
medication. This gives the preschool-aged child a sense of control over a stressful situation and
increases the child's ability to cope.

- "I will be sure to take the albuterol before taking the cromolyn."
- The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier
(cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the
maximum dose of medication will get to the client's lungs.

- Airway patency
- When using the airway, breathing, circulation approach to client care, the nurse determines that
the priority assessment is airway patency. After head and neck surgery, a major, life-threatening
complication is airway obstruction. The priority actions involve airway maintenance and gas
exchange.
- Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.
- Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could
cause the client to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or
coughing and drooling noted with oral intake.

- "If I could lose about 50 pounds, I might stop having so many apneic episodes."
- Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least
five times per hour. Excessive weight is one of the three major risk factors associated with sleep
apnea and is the only one the client can modify (gender and age are the other two). Weight loss
and maintenance are the primary interventions for the treatment of sleep apnea.

- 225 mg X 5 mL/200 mg = X

5.625 mL = X

STEP 7: Round if necessary. 5.625 = 5.6 mL

- Move any clients in the immediate vicinity.

- The greatest risk to clients is injury from smoke and fire; therefore, the nurse’s first action is to
move any clients near the smoke to a safe location. The acronym RACE is a reminder of the
order in which to take steps in the event of a fire. The nurse should rescue the clients, activate
the fire alarm, confine the fire, and extinguish the fire.

- Median vein in the forearm

- The nurse should use the median vein in the forearm because it is distal to other potential
venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural
splinting and protection for IV insertion sites in the forearm and allow more freedom of movement
for the client.

- Keep the drainage system below the level of the client's chest at all times.
- During transport, the drainage system should be kept below the level of the client's chest to
prevent air and drainage fluid from re-entering the thoracic cavity.
- Remove the catheter and insert another into a different site
- It is possible that the catheter is up against a valve or near a nerve and is causing more pain than
an IV catheter insertion should. The nurse should remove the source of the pain and establish
peripheral IV access elsewhere.

- Amylase
- Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the
body. It is produced by the pancreas and salivary glands and released into the mouth, stomach,
and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually
increases within 12 to 24 hr and can remain elevated for 2 to 3 days.

- Combing her hair

- Abduction of the arm is the most difficult, and usually the last, type of movement to be regained
by a client following a mastectomy.

- Measure the circumference of both upper arms.

- The first action the nurse should take using the nursing process is to assess the client. The nurse
should measure the arm and compare the result with the circumference of the other arm. If the
arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could
indicate formation of a clot above the site or even catheter rupture.

- pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

- The nurse should expect a client who has renal failure to have metabolic acidosis, which is
characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges
for these laboratory values are as follows: pH 7.35 to 7.45, HCO 3- 21 to 28 mEq/L, and PaCO2 35
to 45 mm Hg.

- BUN 55 mg/dL
- This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is
nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory
value to the provider before initiating the medication.
- "Do you have a cell phone you can talk to friends and family on?"
- A client who has a radiation implant must remain in radiation isolation. Time and distance are the
factors that reduce exposure to the source. After acknowledging the client's feelings of loneliness
and recognizing the sense of social isolation, this solution provides an appropriate, safe means of
meeting the client's need for contact.

- Candidiasis
- Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults,
and clients whose immune systems have been compromised by illness, such as AIDS, or
medications.

- Checking the pupillary response to light

- Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV
(trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial
nerve is functioning properly, the expected reaction is pupil constriction in response to light.

- "It is no longer possible for you to choke on or aspirate food."

- The surgical procedure of total laryngectomy provides complete anatomical separation of the
trachea and esophagus. Choking and aspiration of food and liquids is no longer possible.

- Review the client's electrolyte values.

- The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles;
therefore, the first action the nurse should take is to review the client's electrolyte values. The
client might have low sodium, potassium, and chloride from frequent diarrhea.

- "I'll wrap a warm, wet towel around my right calf every 4 hours."
- Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the
manifestations of inflammation by increasing blood flow to the affected area. The nurse should
instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and
apply warm, moist heat to the site every 2 to 4 hr.

- a self-report pain rating scale

- Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech
problem. The client who has expressive aphasia is able to understand what is said but is unable
to communicate verbally. However, this does not necessarily mean that a client is unable to
reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the
client’s self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy
of pain measures which begins with self-report. It is always better to use a subjective method,
 such as a client report, instead of an objective method, such as something that is observable by
the nurse, which is much less reliable.

- "I will make a list of my favorite beverages."

- The nurse should work with the client to develop a schedule for fluid restrictions, and should
attempt to include the client’s favorite beverages when possible to promote satisfaction.

- Yellow-green drainage on the surgical incision

- Thick yellow-green drainage is indicative of an infection and should be reported immediately.

- Administer an antiemetic prior to the procedure.

- The nurse can help prevent nausea and vomiting by administering an antiemetic prior to
chemotherapy, and to tell the client to continue taking medication until nausea and vomiting
resolve.

- The fourth heart sound (S4)

- S4 is an extra sound that is heard late in diastole just before S 1. It occurs due to resistance to
blood flow in an enlarged ventricle.

- Recombinant
- The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who
have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure
before an invasive procedure, surgery, or when actively bleeding.

- Montgomery straps
- Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical
wound. The strips have holes so the two sides of the dressing can be tied together and re-opened
for dressing changes without having to remove the adhesive strips. If Montgomery straps are
unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and
place the tape across the dressing onto the hydrocolloid strips.

- Suppress respiratory effort

- Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's
respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work
of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor
lung compliance

- "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
- The nurse should instruct the client that many clients report being disconcerted by the loud
thumping and humming noises produced by the scanner, and for that reason, earplugs are
offered to reduce the discomfort.

- Basal cell carcinoma

- A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders.
Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central
ulceration.

- Hypotension
- Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias.
It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A
major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be
monitored before and during parenteral administration.

- Abnormally prominent U wave

- Although U waves are rare, their presence can be associated with hypokalemia, hypertension
and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for
a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

- Tell the client to blow her nose gently before the instillation.
- Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will
help remove any secretions or crusts that could interfere with the distribution and absorption of
the medication.

- "Abdominal bloating might occur."

- While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.
- Hemorrhagic stroke
- A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including
sudden onset of a severe headache, a decrease in the level of consciousness, and seizures.
Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an
aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

- Bladder infection
- The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a
bladder or kidney infection.

- Airway obstruction
- When using the airway, breathing, circulation approach to client care, the nurse determines that
the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to
the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe
respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this
client's care.

- Adrenocortical insufficiency
- Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the
adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe
allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress
production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of
adrenal insufficiency.

- Apply ice to the affected area.

- Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint.
Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain
and swelling.

- To prevent fluid from accumulating in the wound

- The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents
pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a
 medium for infection. The JP drainage tube is threaded through the skin into the wound near the
surgical incision and is held in place by sutures.

- Suction two to three times with a 60-second pause between passes.

- Copious secretions may require several passes of the suction catheter. An interval of 60 seconds
should be allowed between passes to prevent hypoxia.

- Atelectasis
- Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or
bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective
coughing, and underlying lung disease are risk factors for the development of atelectasis.

- Asthma
- Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause
bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle
relaxation.

- Decreased serum calcium level

- A decreased serum calcium level is an expected finding for FES, although the reason for this
finding is unknown.

- "Large incisions will be made in the eschar to improve circulation."

- An escharotomy is a surgical incision made to release pressure and improve circulation in a part
of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that
encircle a body part, such as an arm or the chest, can cause swelling and tightness in the
affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue
allows the skin to expand, reduces tightness and pressure, and improves circulation.

- "You should report any tendon discomfort you experience while taking this medication."
- The nurse should instruct the client to report any tendon discomfort as well as swelling or
inflammation of the tendons due to the risk of tendon rupture.
- A primary survey is an organized system to rapidly identify and manage immediate threats to life. The
mnemonic "ABCDE" is a reminder of the steps of the primary survey. The first step is "airway," during
which the nurse should establish a patent airway using the jaw-thrust maneuver. The second is
"breathing," during which the nurse should assess the client's ventilator efforts to determine effectiveness
of breaths. During the third step, "circulation," the nurse should establish IV access for fluids and blood
administration as needed. The fourth step is "disability," during which the nurse should determine a
baseline neurologic status by completing a GSC assessment. And the fifth step is "exposure," during
which the nurse should remove the client's clothing to complete a thorough assessment of the client's
injuries.

- A room with air exhaust directly to the outdoor environment

- A room with air exhaust directly to the outside environment eliminates contamination of other
client-care areas. This type of ventilation system is referred to as an airborne infection isolation
room.

- Discontinue suction when assessing for peristalsis is correct. The nurse should turn off
suction while auscultating the abdomen to determine the return of peristalsis because the suction
masks any present bowel sounds.

Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. The client
requires the NG tube for gastric decompression, so the nurse must make sure it remains patent.
Irrigating the NG tube with normal saline irrigation solution every 4 hr will ensure patency.

Place sequential compression devices on the bilateral lower extremities is correct.

Sequential compression devices improve blood flow for clients who have mobility limitations and
help prevent venous thromboembolism in the lower extremities.

Reposition the client from side to side every 2 hr is correct. The nurse should reposition the
client from side to side at least every 2 hr but should also assist with early ambulation to improve
ventilation and help mobilize secretions.

- Dehydration
- Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.

- Hip Arthroplasty
- Clients who are postoperative following orthopedic procedures of the lower extremities and clients
who were placed in the lithotomy position for a procedure, such as for gynecological or urological
surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.

- Cheyne-Stokes respirations
- Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of
hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR
are common respiratory alterations seen in clients who are unconscious, comatose, or moribund
(approaching death).

- The client who has a nasogastric (NG) tube to suction

- Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach.
When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes,
especially potassium, and this loss places the client at risk for hypokalemia.

- It facilitates the client's deep breathing.

- When using the airway, breathing, circulation approach to client care, the nurse should identify
facilitation of deep breathing as the most important desired effect of opioids aside from pain relief.
Following thoracic type surgeries, the client’s has increased pain with moving, deep breathing
and coughing. Opioid medications help minimize the discomfort experienced with deep breathing
and coughing which prevents the development of postoperative pneumonia. The nurse should
also encourage the client to splint his incision to help minimize pain.

- Stop the infusion.

- When using the airway, breathing, circulation approach to client care, the nurse should place the
priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis and the first
action that should be taken is to withdraw the medication.