HURST review (1)

prescription for restraints was received at 3am because of combative behavior. on last assessment at 7am, client was still combative. what is the BEST action? a. continue restraints b. remove restraints until HCP writes prescription c. assign UAP to check on client periodically d. obtain prescription from HCP obtain prescription from HCP *periodical checks is not an acceptable time frame (must give specific hours) how often do you need a prescription for restraints if they are still needed? every 4 hours *should include why they require restraint & period for using them (no longer than 24 hours) 00:18 01:34 post-op care for a thoracentesis: -check vitals frequently -examine dressing for bleeding -listen to and percuss lungs -palpate around incision site for air under skin how should a client be positioned post-op for a thoracentesis? turn them on their unaffected side for at least 1 hour (promote re-expansion of lung and healing of the site) *do not place with affected lung down Nurse is caring for a client prescribed vancomycin for MRSA. what nursing intervention is appropriate? verify the client's BUN and creatinine are in normal range why would muscle spasms in a client who is 28 weeks pregnant complaining of swollen hands and feet be the biggest concern? client could have pre-eclampsia and is at risk for seizures do you need to wear gloves when taking a client's vitals or passing out meal trays? no (not coming into contact with body fluids) when caring for a client who is immunosuppressed, what precautions are needed? standard when is a N95 mask placed on a client? airborne precautions (ex. TB) what is a common effect/SE of an SSRI? increased sweating *SSRI's may cause temperature dysregulation *should have a lessening of depressive symptoms within a few weeks assessment findings common with cirrhosis: firm, nodular liver ascites increased ALT and AST levels bleeding from GI tract LOW serum albumin levels (sick liver = less proteins) Kosher diet No pork (bacon, ham, or sausage) no shellfish (but yes normal fish) steak must not have any traces of blood milk is not allowed at same time as meat 00:02 01:34 Client with gout is being treated with NSAID for acute flare up. what is the expected finding? dramatic decrease in pain after beginning medications *patient's with gout usually experience dramatic improvement within 24 hours *NSAID's do not reduce plasma uric acid levels are a low-grade fever and rash adverse effects of NSAIDs? no! *NSAIDs prevent fever, biggest SE is GI upset if a client at 32 weeks gestation is admitted to OB unit with BP of 142/90 and 1+ proteinuria, who should the nurse assign her to share a room with? another client with possibility of preterm delivery (not one with potential emergency) *room should be kept quiet to decrease stimulus Why would a post-partum client be a bad choice to share a room with a client who has pre-eclampsia? newborn would require frequent post-partum assessments and nursing care *great deal of activity in the room can an LPN re-insert an NG tube that a client pulled out? yes can LPN monitor PCA pump pain medication is being delivered? yes (cannot initiate or administer pain meds -just monitor the pump) can a LPN collect data on a new client? yes, if the RN verifies and co-signs to complete assessment what developmental tasks would the nurse expect to see in a young adult developing meaningful and intimate relationships giving and sharing with an individual without asking what will be done in return during what age group do people find a sense of fulfillment that can be found by volunteering in the community? middle age (finding ways to support others) what age group must find some way to satisfy and support the next generation? middle adulthood (parenting task) what age group do people reflect on their life accomplishments late adulthood what is the best instruction for a UPA who is caring for a client with Alzheimer's that keeps walking into other rooms on the unit? hang a familiar object on the door (client's with alzheimer's may not recognize their own name or take time to read) s/s of acute rejection (kidney) fever increased BUN/creatinine decreased UO increased BP tenderness over the kidney nurse is planning teaching to a group of assisted living residents (close quarters, ex. dorm) about TB. what should the include? cover mouth when coughing proper hand washing obtain TB skin test proper disposal of tissues (hygiene measure) s/e of a client who has received too much levothyroxine: -angina -heat intolerance -tremors (replacement hormone for hypothyroidism, would be showing s/s of hyperthyroidsism / CAD) foot care for diabetics: check shoes for rough spots file toenails straight across (instead of cutting) break in new shoes gradually (30-60 min/day) avoid self-care for corns/calluses (contact HCP first) which rhythm change would be a priority for the nurse to assess? bradycardia -- will decrease CO / perfusion to vital organs (a fib/a flutter is not as life threatening) can a UAP collect a stool specimen? yes (not urine from catheter, sterile procedure) can a UPA apply cardiac leads and connect to cardiac monitor? yes can a UAP feed a client who is dysphagic? no *risk of aspiration, need an RN present what tag would a client receive if they had a BP 40, HR 30, and respirations 6? black *nurse would not assess in a disaster what color tag would a patient with a sucking chest wound and tension pneumothorax receive in a disaster? red (life threatening injury; but can be helped if care is quick!) therapeutic serum levels of digoxin: 0.5-2 ng/mL is performing a postop wound dressing change using clean gloves cost-effective care? no *need sterile gloves, infection is more expensive than gloves what is an example of cost effective nursing care? -providing palliative care to a terminally ill client (reduces unnecessary resources) -beginning discharge planning on admit -counseling clients to quit smoking -educating parents on importance of immunizations why is "pre op diazepam 10.0 mg given PO" not correct documentation? don't use trailing 0's (same as not using a leading 0 -- 0.5 not .5) is "appears to be having abdominal discomfort" correct documentation? no, subjective if a client has a Apgar score of 4, 5, or 6 at 5 minutes: what is the nurses priority intervention? administer "blow-by" oxygen while suctioning *requires immediate intervention; transferring them to an ICU will delay care (NOT RIGHT) if a client is admitted for suspected sepsis (temp 102.2 and lethargic) what action is priority? blood cultures x 2 or start an IV/start fluids blood cultures! *IV can be started at any point *should get blood cultures before IVF's so blood sample is not affected in any way should crust be removed from insertion site of Steinmann pins? yes, but not a priority "my veins have turned to stone and my heart is solid" is an example of: depersonalization *feeling detached to reality, feeling that their parts have changes or sense of seeing oneself from a distance client with Schizophrenia who is purposelessly imitating movements by others is exhibiting: echopraxia invention of new words by psychotic patients is called neologism normal aPTT level when on an anticoagulant 60-80 seconds if a client is on heparin and their aPTT is 110 seconds, what should you do? Administer protamine sulfate normal aPTT 25-35 seconds heparin overdose = protamine sulfate what is monitored in a patient on warfarin? PT and INR if a client states "I don't have any help taking care of my baby. I don't feel like I can take care of him anymore. I wish I never had him. maybe then my husband would spend more time at home" what should you say? come to the clinic right now *assume the worst (exhibiting s/s of postpartum psychosis) *think: suicide or infanticide patency of AV shunts: auscultate bruit palpate thrill