NCLEX RN Mastery with rationale Exam With Complete

NCLEX RN Mastery with rationale The nurse is caring for a client with suspected meningitis after a lumbar puncture was performed. Which of the following indicates an expected outcome after the procedure? A. The client has a small amount of bloody drainage at the insertion site. B. The client has pupils of unequal size. C. The client has a small hematoma at the insertion site. D. The client reports a HA with mild dizziness - The client reports a HA with mild dizziness (HA is a mild but common complication that occurs in 10-30% of clients in the hours following the procedure, and maybe be accompanied by dizziness, N/V, tinnitus, and visual changes) What is a lumbar puncture procedure used to diagnose? - ~ Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis ~ Bleeding around the brain (subarachnoid hemorrhage) ~ Certain cancers involving the brain or spinal cord ~ Certain inflammatory conditions of the nervous system, such as multiple sclerosis and Guillain-Barre syndrome Complications of lumbar puncture (spinal tap)? - infection, bleeding, sudural hematoma formation, and cerebral herniation What is a lumbar puncture and what is the patient's positioning? - During a lumbar puncture (spinal tap) procedure, you typically lie on your side with your knees drawn up to your chest. Then a needle is inserted into your spinal canal — in your lower back — to collect cerebrospinal fluid for testing. The nurse is supervising care of a graduate nurse performing gastric lavage on a client with Acetaminophen overdose. The nurse should intervene if which action is observed? A. Iced solution is instilled to promote vasoconstriction B. Changes in VS and LOC are monitored C. The client is placed in side-lying Trendelenburg D. A large bore (38 F) tube is inserted for instillation of lavage fluid - A. Iced solution is instilled to promote vasoconstriction (A warm solutiom should be instilled to prevent irritation of the vagal nerve as well as dangerous temp changes in client) What is Gastric Lavage? Why is it performed? - ~ A procedure that uses a nasogastric tube to "pump" the stomach, rinsing the gastric organ out with another fluid. An NG tube is inserted, instilled with fluid, and then the contents are aspirated, either intermittently or continuously. ~ Used in clients after a drug overdose or in clients with GI bleeding to clean the GI tract of clots and residue in preparation for endoscopy How do you know if an NG tube is placed correctly? - ~ Most tubes have a radiopaque marker or strip at the distal end to help confirm the tubes placement. ~ Aspirate for stomach contents and test the pH for secondary confirmation. What is the typical gastric fluid appearance? - ~ Grassy green, clear and colorless with mucous shreds, or brown ~ the pH is less than or equal to 5.0 How do you determine how long an NG tube must be to reach the stomach? - Hold the end of the tube at the tip of the patient's nose. Extend the tube to the patient's earlobe and then to the xiphoid process. What are the diagnostic and therapeutic applications of an NG tube? - ~ assessing and treating upper GI bleeding ~ collecting gastric contents of analysis ~ peforming gastric lavage ~ aspirating gastric secretions ~ administering medication and nutrients The nurse is caring for a post-op client with a BUN of 60 mg/dL and a creatinine level of 3.2 mg/dL. The provider has ordered an infusion of 1 L of 0.9% NaCl with 40 mEq KCl to be administered over 2 hours. Which of the following is a priority nursing action? A. Assess the client's urinary output. B. Administer the IV fluid replacement. C. Question the infusion of 0.9% NaCl with 40 mEq KCl. D. Encourage the intake of protein rich foods in diet. - ~ The order for 1 L of 0.9% NaCl with 40 mEq KCl should be questioned. Increased blood urea nitrogen and creatinine indicate renal dysfunction. Elevated BUN can indicate dehydration, but the creatinine also indicates renal problems. ~ Fluids should be monitored as the kidneys may not efficiently clear excess fluids and maintain fluid balance. ~ The kidneys are responsible for fluid and electrolyte regulation Potassium is excreted by the kidneys, and if it is not cleared from the body, excess potassium will lead to cardiac issues. Should patient's with renal insuffiency be encouraged to eat a protein rich diet? - No. Urea products from protein are cleared by the kidney and could build up with renal insufficiency, so encouraging protein intake is not a good intervention until BUN and creatinine labs improve. The nurse is caring for a client following a TURP procedure. Which of the following findings most concerns the nurse? A. HR of 116 bpm B. Small blood clots in the urine C. Urine output of 20 mL/hour D. Urinary retention - Heart rate of 116 bpm, could be a sign of infection. This symptom, along with fever, should be monitored for and reported after surgery. Clients who undergo a TURP are at risk for both local and systemic complications. What is a TURP and what's it for? - A transurethral resection of the prostate involves surgical insertion of a thin instrument called a resectoscope through the urethra. Some of the prostate tissue surrounding the urethra is trimmed away enlarging the lumen of the urinary channel to relieve symptoms of BPH.