The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? Show 3. mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema). Which action would the nurse anticipate implementing when caring for a client with acute respiratory distress syndrome who is intubated and on mechanical ventilation? 3. determine the need for suctioning based on clients assessments Suction is likely to be needed and will be done based on assessment data such as client oxygen saturation, breath sounds, and activation of the high pressure alarm signifying endotracheal tube obstruction. The endotracheal tube cuff is kept inflated to protect the lower airways and improve delivery of breaths to the lungs. Research indicates that daily changes in ventilator tubing increase the risk for ventilator-associated pneumonia; the ventilator tubing should be changed only when soiled. Because high FiO2 levels can cause damage to the lungs, the FiO2 is reduced as the client's oxygenation improves.
Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 4. Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs. Which clinical indicators would the nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. One, some, or all responses may be correct. 1. Crackles Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin. The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? 4. Uncompensated respiratory acidosis The increased PaCO2 indicates respiratory acidosis and the low pH indicates that the respiratory acidosis is uncompensated. The PaO2 is normal, indicating that the client is not hypoxemic. The elevated PaCO2 indicates hypercapnia. The HCO3 is normal, indicating that there is no metabolic acidosis.
A client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess? Select all that apply. One, some, or all responses may be correct. 2. Dehydration In the diuretic phase, excretion of fluids retained during the oliguric phase occurs and may reach 3 to 5 L daily; unless fluid replacement occurs, dehydration and hypovolemia is a potential. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase. The nurse is notified that the latest potassium level for a client who has acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action would the
nurse take? 3. Notify the primary health care provider. The primary health care provider must treat this hyperkalemia to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Obtaining an antiarrhythmic is premature, there is no evidence of dysrhythmia. A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, which would the nurse expect to observe? 2. Steatorrhea Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon. A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F (38.3°C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, which clinical finding is a primary nursing concern for this client? 1. Acute pain Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. Although clients with this medical diagnosis often are malnourished, addressing the client's pain takes priority. There are not enough data to determine electrolyte imbalance; additional data, such as for skin turgor, serum electrolytes, and intake and output, are needed to identify whether the client has a fluid and electrolyte imbalance. There are no data to support the presence of a disturbed self-concept. The nurse reviews the laboratory results of a client with acute pancreatitis. Which test is significant in determining the client's response to treatment? 2. Amylase level In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times above baseline; serum amylase usually returns to expected adult levels within 3 days after treatment begins. The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis. A client is diagnosed with chronic pancreatitis. Which dietary instruction is important for the nurse to share with the client? 3. Avoid ingesting alcoholic beverages. Alcohol will cause the most damage. It increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should consume a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories also are recommended. The nurse administers lactulose to a client with cirrhosis of the liver. Which laboratory test change leads the nurse to determine that the lactulose is effective? 2. Decreased ammonia Lactulose destroys intestinal flora that break down protein and, in the process, give off ammonia. In clients with cirrhosis, ammonia is inadequately detoxified by the liver and can build to toxic levels. Amylase levels are associated with pancreatic problems. Increased potassium levels are associated with kidney failure. Hemoglobin is increased when the body needs more oxygen-carrying capacity, such as in smokers, or in high altitudes. The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations would the nurse assess in the client? Select all
that apply. One, some, or all responses may be correct. 1. Ascites Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver. A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any postprocedural risks. How would the nurse respond? 3. "The major risk is bleeding." The major postprocedural risk for this client is bleeding. In many clients with liver dysfunction, such as cirrhosis, the liver has lost its ability to synthesize proteins, such as clotting factors. The major postprocedural risks are not pneumonia, infection, or liver failure; bleeding is a higher risk. A client with Laënnec cirrhosis has a Sengstaken-Blakemore
tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. Which is the nursing priority? 1. Implement fall precautions and/or prevention measures. Measures must be taken immediately to ensure client safety. The administration of an antianxiety medication may be needed, but it is not the priority. Although verifying correct tube placement is important, the nurse should first take measures to ensure client safety. Determining the correlation of laboratory value results with the client's confusion may be helpful, but it is not the priority. he nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a
prescription for neomycin enemas based on which abnormal laboratory test? 1. Ammonia level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas. A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for
the procedure? 1. Instruct the client to void. The bladder must be emptied to avoid trauma during insertion of the trocar. Giving the client an analgesic is not necessary. Systemic analgesics may mask the symptoms of shock, a potential complication. The semi-Fowler position is used to allow fluid to accumulate in the lower abdominal cavity so that it can be accessed by the trocar. After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. One, some, or all responses may be correct. 1. Confusion Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs. Which collaborative action would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.24, PaCO2 60 mm Hg (7.98 kPa), HCO3 20 mEq/L (20 mmol/L), PaO2 54 mm Hg (7.18 kPa), and O2 saturation 88% (0.88)? 3. Intubation and mechanical ventilation The client's low pH, high PaCO2, low HCO3, low PaO2, and low oxygen saturation indicate respiratory failure and the need for mechanical ventilation. The client has respiratory acidosis due to poor ventilation and CO2 retention and lactic (metabolic) acidosis secondary to hypoxemia. Oxygen at 6 L/minute will not be adequate to resolve hypoxemia. Nebulized albuterol would improve ventilation, but not enough to resolve the respiratory acidosis. Sodium bicarbonate would help correct pH and HCO3, but would not correct hypoxemia. Which findings would the nurse anticipate when reviewing the laboratory reports of a client with an acute kidney injury? Select all that apply. One, some, or all responses may be correct. 1. Calcium: 7.6 mg/dL (1.9 mmol/L) Which action would the nurse take when suctioning a client's endotracheal tube? 1. Hyperoxygenate with 100% oxygen before and after suctioning. Suctioning can lead to hypoxemia and the nurse would minimize this by hyperoxygenating the client before and after each suctioning attempt. Because suctioning irritates the airway and leads to transient hypoxemia, suctioning should be performed only as needed to maintain a patent airway. One suctioning pass is frequently adequate to clear secretions; excessive suctioning irritates the mucosa, which increases secretion production. Short, pushing movements can cause tracheal damage. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting. When caring for a client who is receiving mechanical ventilation through an endotracheal tube, which collaborative action would the nurse
anticipate when the client's partial pressure of end-tidal carbon dioxide (PETCO2) is 60 mm Hg? Increase respiratory rate setting. Normal PETCO2 ranges from 20 to 40 mm Hg. A value of 60 mm Hg is high and indicates hypoventilation, which would be corrected with an increase in respiratory rate. Because the client is hypoventilating, extubation would not be planned yet. There is no indication that the client is hypoxemic. Administration of sedative medications would further decrease the respiratory rate. The nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions? Humidify the prescribed oxygen Because the client has an endotracheal tube in place, secretions can be loosened by administering humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs. A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? Suction the tracheostomy. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem-solving may require readjustment of the tracheostomy tube and ties or a health care provider changing the tracheostomy tube. A client has a tracheostomy tube with a high-volume, low-pressure cuff. The
nurse understands that type of cuff is designed to prevent which occurrence? Mucosal necrosis These cuffs do not compress the capillary beds and thus do not cause tracheal damage. A minimal air leak is desirable to ensure the lowest possible pressure in the cuff while still maintaining placement of the tube. Surgical asepsis, not the use of these cuffs, prevents infection. Secretions are increased because the cuff is a foreign body in the trachea. A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? The tracheostomy tube interferes with effective coughing. Because the tracheostomy tube enters the trachea below the glottis, the client is unable to close the glottis to retain air in the lungs; this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough. Humidified oxygen decreases the need for suctioning because it liquefies secretions, which then are easier to expel. The outer, not inner, cannula of a tracheostomy tube irritates the mucosa. Weaning begins when the respiratory status improves and the amount of respiratory secretions subsides. Which action would the nurse anticipate implementing when caring for a client with acute respiratory distress syndrome who is intubated and on mechanical ventilation? Determine need for suctioning based on client assessments. Suction is likely to be needed and will be done based on assessment data such as client oxygen saturation, breath sounds, and activation of the high pressure alarm signifying endotracheal tube obstruction. The endotracheal tube cuff is kept inflated to protect the lower airways and improve delivery of breaths to the lungs. Research indicates that daily changes in ventilator tubing increase the risk for ventilator-associated pneumonia; the ventilator tubing should be changed only when soiled. Because high FiO2 levels can cause damage to the lungs, the FiO2 is reduced as the client's oxygenation improves. Which action would the nurse take to decrease risk for ventilator-associated pneumonia (VAP) in a client who is receiving mechanical ventilation? Elevate the head of the bed to at least 30 degrees. Elevating the head of the bed to 30 to 45 degrees helps reduce aspiration and decreases incidence of VAP. Suctioning is done only when assessment data indicate that it is necessary. Changes of ventilator tubing increase the risk for VAP, and tubing changes are recommended only when there is visible soiling of the tubing. Sedation should be interrupted at least daily to allow evaluation of client respiratory effort and possible readiness for extubation. The
nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action? Opening collapsed alveoli and keeping them open The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps open collapsed alveoli and keeps them open. With the primary mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon dioxide and oxygen can take place more efficiently, thus improving oxygenation by providing more oxygen to the lung tissue and improving gas exchange. PEEP does not force pressure into lung tissue. PEEP may have an indirect effect on opening bronchioles. A client is intubated and receiving mechanical ventilation. The nurse reports to the client's room when the ventilator alarms. Which nursing action indicates that the ventilator was signaling a high-pressure alarm? The nurse removes secretions by suctioning. Secretions in the airway will increase pressure by blocking air flow and must be removed. The nurse must identify/correct the problem so that the set tidal volume can be delivered. Connections that are not intact would cause a low-pressure alarm. ABGs are used to assess client status, but they are not taken each time a pressure alarm is heard. The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action? Remaining with the client to assess responses This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress (e.g., shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, and tachypnea). Performing frequent lung sounds is important, but observation takes priority; it will allow the nurse to quickly identify signs of respiratory distress. Monitoring the saturation levels should be done more frequently, but direct observation is more important. Teaching family members to help with providing a calm environment is helpful but not the priority. A client is receiving mechanical ventilation. The nurse suspects that the client is experiencing poor oxygenation based on which assessment finding? Increased restlessness Signs of poor oxygenation in the client on a ventilator may include increased restlessness or agitation. They may also include, but are not limited to, PaO2 less than 90; cyanosis; skin pale, cool, and clammy; and thick, tenacious secretions present when suctioned. Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place? 3. "Restraints are a last resort to prevent accidental extubation." Restraints are a last resort to protect the airway and are only used as long as necessary. The need for restraints is evaluated frequently, and restraints are discontinued as soon as the client is able to understand and comply with the need to not pull or attempt to reposition the endotracheal tube. The need for restraints will be reassessed at least every 24 hours and a new prescription obtained if restraints are still needed. It is not a requirement to restrain all clients who have breathing tubes. Restraints are never considered routine practice for intubated clients. A client
is receiving mechanical ventilation. When condensation collects in the ventilator tubing, which action would the nurse take? Drain the fluid from the tubing. Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid, and others have to be temporarily disconnected while the fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Humidity is necessary to preserve moistness of the respiratory tract and to help liquefy secretions. The amount of condensation is irrelevant when recording total intake and output. A client with a pulmonary embolus is intubated and placed on
mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube? Hyperoxygenating with 100% oxygen before and after suctioning Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage. When
a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take first? Establish an airway and stabilize the cervical spine. The initial actions after a traumatic injury are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment, after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability. Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? Place the head and neck in neutral alignment. The nurse would first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol. The nurse would notify the health care provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP. A client with carotid atherosclerotic plaques had a right carotid endarterectomy performed 2 hours ago. Which intervention would the nurse implement when the client begins to demonstrate clinical manifestations of progressive hypotension? Notify the health care provider immediately The health care provider must evaluate the cause of the hypotension. Increasing the IV flow rate is a dependent function requiring a health care provider's prescription. Raising the head of the bed will further decrease blood flow to the brain. The nurse would not place the client in a Trendelenburg position because of the increased pressure created within in the carotid arteries. Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? Maintain an open airway. A patent airway is the priority because the airway may become occluded by the tongue in an unconscious client. Monitoring vital signs is not the priority, although it is an important nursing function. Monitoring pupil response and equality and maintaining Fluids and Electrolytes are not the priority, although they are important nursing functions. Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one
pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? Increased intracranial pressure Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction. Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? Lethargy Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases. Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. Which physiological response is responsible for this medication's therapeutic effect? Reduced cerebral edema Dexamethasone is a corticosteroid with anti-inflammatory effects, which will reduce cerebral edema. Dexamethasone will not keep the tumor from growing; it will reduce fluid content and therefore cell size, not the number of cells. Dexamethasone does not promote fluid reabsorption, which is undesirable because it increases fluid retention and therefore cerebral edema. Dexamethasone does not promote sedation; sedation is not desired because it may mask the client's adaptations to the craniotomy. A client has a brain attack (stroke) that
involves the right cerebral cortex and cranial nerves. Which areas of paralysis would the nurse expect to find upon assessment? Select all that apply. One, some, or all responses may be correct. Left leg Because nerves decussate (cross over), paralysis occurs on the side of the body opposite to the area of cerebral involvement. The right leg and right arm will not be affected because the insult is to the right cerebral cortex, and nerve fibers decussate before reaching the periphery. The face is innervated by the seventh cranial nerve, which comes in pairs (right and left) that do not decussate; therefore because injury is to the right cerebral cortex, the left seventh cranial nerve is damaged. This leads to paralysis of the left side of the face. CPP calculation The CPP can be calculated by the following equation: CPP = MAP - ICP. If the MAP is 97 mm Hg and ICP is 12 mm Hg, the CPP is 85 mm Hg. The nurse is planning care for an immobilized client who had a stroke with right-sided hemiparesis. Which activity would the nurse include in the plan of care? Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours. Range-of-motion exercises should be performed often to prevent muscle atrophy and contractures. Assessing the client's lung sounds every 8 hours is the minimum the nurse would assess lung sounds and it is important, but it is not a priority in planning care for immobilization. The client should not be allowed to sit in a chair for prolonged periods of time because of skin breakdown and venous return. The nursing assistant should be instructed to turn the client at least every 2 hours. The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How will the nurse respond? "It is not advisable because bleeding will increase." An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response "It is inadvisable because it masks the effects of the hemorrhage" is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage. Which action is the priority for a client who is admitted to the hospital with a severe head injury? Maintain ventilation. The brain requires continuous, large quantities of oxygen to function; maintaining the airway and ensuring respiratory exchange and ventilation are the priorities. Although preserving skin integrity and preventing contractures is a concern, those are not the priority at this time. Although monitoring the blood pressure is done because a widening pulse pressure may indicate increasing intracranial pressure, it is not a higher priority than maintaining ventilation. The nurse provides postoperative care to a client who has undergone a hypophysectomy. Which action would the nurse take if there is a yellowish discharge at the dressing site? Inform the primary health care provider. To reduce the risk of further complications, the nurse would inform the primary health care provider. Leakage of cerebrospinal fluid (CSF) may occur due to hypophysectomy. A yellowish discharge at the dressing site indicates the leakage of CSF. Changing the dressing, cleaning the wound with alcohol, and tightening the dressing may complicate the condition. A
client has dysarthria after a stroke. Which goal would the nurse include in the plan of care to address this problem? Effective communication Clients with dysarthria have difficulty communicating verbally, and an alternative means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration. The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20 mm Hg. Which action made by the client is responsible for the reported ICP? Bending over at the waist Clients without a pituitary gland (hypophysectomy) should avoid bending at the waist because this position increases intracranial pressures. Drinking lots of water and eating high-fiber foods reduce the risk of constipation, so this should not cause increased intracranial pressure. The client should bend the knees to lower the body, which reduces the risk of increased intracranial pressures. The nurse is assessing a client
who has a head injury. Which movement of the client's arm after the nurse applies nailbed pressure would cause the most concern? Extending Greater cerebral injury leads to less purposeful movement. Abnormal upper arm extension is characteristic of decerebrate (extension) posturing in severe brain injury; the only more serious response is total lack of response. Flexion (characteristic of decorticate posturing), withdrawing, or localizing are associated with less severe brain injuries. A client who sustained a head injury from a fall off a ladder has clear fluid leaking from the left ear. Which action would the nurse take? Test the ear drainage with a glucose reagent strip. If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable. Irrigating the ear canal may introduce bacterial into the open skull fracture and into the brain, causing infection. Turning the client to the unaffected side will allow fluid to collect in the ear, and more importantly, manipulation of the neck while turning the client may cause further injury. Packing sterile cotton in the ear may cause further trauma, and it does not help in determining the source of the fluid. Which physical assessment findings would the nurse document on a client who is experiencing Cushing triad? Select all that
apply. One, some, or all responses may be correct. Bradycardia A client experiencing Cushing triad presents with bradycardia (with a full and bounding pulse), irregular respirations, systolic hypertension, and a widening pulse pressure. These clients do not experience tachycardia or diastolic hypertension. Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? Temporary episodes of neurological dysfunction Narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period. Between attacks, neurological functioning is normal. Emboli result in a brain attack (cerebrovascular accident [CVA]); with a CVA the damage is usually permanent, not intermittent. Ischemic attacks that result in progressive neurological deterioration occur with multiple small brain attacks; TIAs do not result in permanent damage. Exacerbations of neurological dysfunction alternating with remission are not the description of a TIA; remissions and exacerbations occur with progressive degenerative neurological disorders. What are strategies to prevent ventilator associated pneumonia?Several strategies have been described to achieve this goal: non-invasive positive pressure ventilation (NPPV), sedation holidays, weaning trials, avoiding re-intubation, and early tracheostomy have all been studied as methods to decrease time of mechanical ventilation and therefore, decrease the risk of VAP.
What are some interventions that may be included in a ventilator associated pneumonia VAP bundle?The bundle includes these interventions:. head-of-bed elevation above 30 degrees.. peptic-ulcer disease (stress ulcer) prophylaxis.. deep-vein thrombosis prophylaxis.. appropriate sedation use (“sedation vacation”).. Which nursing action may help prevent ventilator associated events VAEs )?Clinical Conditions Associated with VAEs. ... . Strategic Framework for Preventing VAEs. ... . Strategy 1: Minimize Sedation. ... . Strategy 2: Perform Daily Coordinated Spontaneous Awakening Trials and Breathing Trials. ... . Strategy 3: Implement Programs for Early Exercise and Mobility. ... . Strategy 4: Low Tidal Volume Ventilation.. What is the VAP protocol?The VAP is defined as a respiratory tract infection developed after 48 hours of intubation with mechanical ventilation or within 48 hours after disconnecting the ventilator.
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Which action would the nurse take to decrease risk for ventilator associated pneumonia VAP in a client who is receiving mechanical ventilation?
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