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, HCO3- 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 S1. 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.