Download NUR 283 Comprehensive 1 Study Guide 2024 - Galen College of Nursing and more Exams Nursing in PDF only on Docsity!
NUR 283 Comprehensive 1 Study Guide 2024 -
Galen College of Nursing
For patients prescribed digoxin monitor apical pulse rate for one full minute. Recognize and report changes (irregular rate with early or extra beats). Teach to withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. GI effects include anorexia (usually the first manifestation of toxicity), nausea, vomiting, and abdominal pain. CNS effects include fatigue, weakness, vision changes (blurred vision, yellow- green or white halos around objects). Teach the patient to monitor for these effects and report to the provider if they occur. One of the scenarios this week is about IV infiltration. When caring for a patient that develops IV phlebitis manifestations, what are appropriate nursing actions? For any peripheral IV, if the site is red and swollen upon assessment the next action is to remove the IV. Phlebitis/infiltration from the IV requires the nurse to document in the medical record as well as complete an incident report. Document objectively a description of the facts and your actions. Do not document in the medical record that an incident report was completed. The incident report is for the risk management department in the organization. Again, only document the facts and nursing actions taken. Do not state in the medical record that you completed an incident report. For older adults a 19 or 20g is indicated due to fragile skin. Protect the skin of older adults with IV insertion by using a soft cloth between the tourniquet and skin or a blood pressure cuff inflated 10 to 15 cm (4 to 6 in) above the insertion site to compress only venous blood flow. Interventions for patients with digoxin toxicity:
- Monitor VS
- Stop digoxin and potassium-wasting diuretics immediately.
- Monitor K+ levels. For levels less than 3.5 mEq/L, administer potassium IV or by mouth. Do not give any further K+ if the level is greater than 5.0 mEq/L or AV block is present.
- Treat dysrhythmias with phenytoin or lidocaine.
- Treat bradycardia with atropine.
- For excessive toxicity, activated charcoal, cholestyramine, or digoxin immune Fab can be used to bind digoxin and prevent absorption.
You previously learned about Total Enteral Nutrition (TEN) and tube feedings. Enteral feedings are instituted for a client who has a functioning GI tract but is unable to swallow or take in adequate calories and protein orally. It can be in addition to an oral diet, or it can be the only source of nutrition. What are best practices for tube-feeding care and maintenance for these patients? See best practice boxes on page 1206 in IGGY 10th edition med/surg book, Tube Feeding Care and Maintenance and Maintaining a Patent Feeding Tube.
- For g tube or j tube rotate tube 360 degrees each day and notify provider if tube cannot be moved.
- Check residual every 6 hrs or per agency policy for clients receiving enteral feedings to decrease the risk of aspiration. Do not discard the residual. Follow facility policy as most or all of the residual should be replaced into the patient’s stomach to prevent fluid, electrolyte, and nutrient loss.
- For continuous feedings add only 4 hours of product to the bag at a time to prevent bacterial growth. Discard unused open cans after 24 hours.
- Change feeding bag and tubing every 24-48 hours. Replace irrigation set at least every 24 hours.
- Do not use any food dye color in formula.
- Keep HOB elevated at least 30 degrees during the feeding and for at least 1 hour after the feeding (if bolus feedings) to prevent aspiration. For cyclic or continual feedings maintain semi-Fowler’s position.
- A clogged tube is the most common problem. Flush tube with water: o Every 4 hours during continuous tube feedings o Before and after intermittent tube feeding o Before and after drug administration o After checking residual volume The NCLEX category Pharmacological and Parenteral Therapies has a section titled Parenteral/Intravenous Therapies (page 32 of test plan). Monitor intravenous infusion and maintain site is an activity statement noted for this part of the test plan. Registered nurses have a duty to ensure the infusion rate is correct and monitor the site for clinical indications the IV should be removed and rotated to a different site. Manifestations of phlebitis include redness/erythema, inflammation, and tenderness at IV site. Failure to detect an error with an IV could result in infiltration or extravasation. Monitor the rate and site closely. Intervene if needed to prevent pain, swelling, compartment syndrome or, in extreme cases, an amputation of the affected limb.
tubing. Then notify the provider and send the blood bag and administration set (tubing) to the lab for testing. Respiratory and cardiac assessment is important for all patients. Students sometimes have trouble remembering correct assessment technique for auscultating heart and lung sounds as well as correct descriptions of lung sounds. Where would you place the stethoscope to auscultate the pulmonic valve and what are considered normal breath sounds? Place the stethoscope on the second intercostal space, LEFT of the sternal notch, to auscultate opening and closing sounds of the pulmonic valve. This is the opposite side of the sternal notch for auscultating the aorta opening and closing, which would be second intercostal space, right sternal notch. You should know where to place the stethoscope to listen to lung and heart sounds. This is fundamental nursing knowledge. Normal breath sounds include bronchial, bronchovesicular, and vesicular depending on the areas auscultated. See IGGY med/surg book for details on normal vs abnormal breath sounds. Characteristics of Normal Breath sounds are in table 24.4 in IGGY 10th edition book. Auscultation is the process of listening to sounds the body produces to identify unexpected findings. Some sounds are loud enough to hear unaided (speech and coughing), but most sounds require a stethoscope or a Doppler technique (heart sounds, air moving through the respiratory tract, blood moving through blood vessels). Learn to isolate the various sounds to collect data accurately.
- Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like).
- Use the diaphragm of the stethoscope to listen to high-pitched sounds (heart sounds, bowel sounds, lung sounds). Place the diaphragm firmly on the body part.
- Use the bell of the stethoscope to listen to low-pitched sounds (unexpected heart sounds, bruits). Place the bell lightly on the body part. Blood is a medium for bacterial growth, any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four hours, placing the client at risk for septicemia. Try this practice question and provide a rationale for your response: You are caring for a client who is 34 weeks gestation, has a hematocrit of 28 mg/dL. The provider prescribes iron supplementation. Which teaching should the nurse provide? Select all that apply.
- "Take the iron pill in the morning with eggs."
- "Take the iron pill every other day for best benefit”
- "Eat some strawberries when taking the iron pill."
- "Drink a full glass of milk when taking the iron pill."5. "Drink a glass of orange juice when taking the iron pill." Answer: 3 and 5 are correct. 1 is not correct. Taking the iron supplement with eggs is not recommended. Eggs decrease the absorption of iron. It is recommended to take iron supplements at bedtime to avoid GI upset. 2 is not correct. The iron needs to be taken daily in order to provide maximum effectiveness. 3 is correct. Strawberries are high in Vitamin C and will help with absorption of iron. Vitamin C increases absorption of iron. 4 is not correct. Calcium rich foods such as milk and beverages (tea/coffee) will decrease iron absorption. 5 is correct. Orange juice is high in Vitamin C and will help with absorption of iron. Also a good choice to mix with a liquid dose, straw indicated to avoid staining of teeth. Encourage the patient to consume iron rich foods. Iron rich foods include:
- Meat
- Fish
- Poultry
- Tofu
- Dried peas and beans
- Whole grains
- Dried fruit
- Iron-fortified foods
- Leafy greens, such as spinach, kale, swiss chard, collard and beet greens Digoxin improves the heart’s pumping effectiveness and increases cardiac output and stroke volume. It decreases heart rate by slowing depolarization through the SA node, thus allowing more time for the ventricles to fill with blood. Due to these effects, digoxin is used to treat heart failure, atrial fibrillation, and some other tachydysrhythmias. Try this practice question and provide a rationale for your response: A nurse is teaching a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include in the teaching?
- Contact provider if heart rate is less than 60/min.
- Check pulse rate for 30 seconds and multiply result by 2.
including pain and tenderness at the transplant site. Also watch for tachycardia and fever. These patients will continue to have some blood in the urine post-op so pink-tinged urine is not uncommon. It will take up to a few weeks for the urine color to return to normal after a kidney transplant. Table 63.13 in IGGY notes presentation of three types of rejection for these patients: hyperacute, acute, and chronic. Hyperacute features appears within 48 hours after transplant: increased temp, increased BP, pain at site. Treatment is removal of transplanted kidney. Acute rejection features can appear from about 1 week after surgery to any time after surgery: oliguria or anuria, temp over 100, increased BP, enlarged, tender kidney, lethargy, elevated creatinine, BUN, and K levels with fluid retention. You need to know normal lab values so you can recognize abnormal. Treatment is increased doses of immunosuppressive drugs. Chronic rejection features can appear gradually during a period of months to years after transplant: gradual increased in BUN and creatinine, fluid retention, change is electrolyte levels, and fatigue. Treatment is conservative until dialysis is required. Immediately notify the surgeon if any manifestations of organ rejection appear. IGGY 10th edition page 1407 notes the different types of rejection associated with kidney transplant. Also, make note of the critical rescue box on same page. Notify provider if hypotension or excessive diuresis occurs as this reduces blood flow to the new kidney and threatens graft survival. Try this practice question and provide a rationale for your response: A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for manifestations of complications associated with peritoneal dialysis. Select all that apply.
- Pruritus
- Oliguria
- Tachycardia
- Cloudy outflow
- Abdominal pain
- Nausea/Vomiting Answer: 3, 4, 5, 6
1 is not correct. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. 2 is not correct. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis. 3 is correct. Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. 4 is correct. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. 5 is correct. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. 6 is correct. Nausea and vomiting are manifestations of peritonitis Spontaneous rupture of membranes can initiate labor or can occur anytime during labor. Labor usually occurs within 24 hr of the rupture of membranes. Prolonged rupture of membranes greater than 24 hr before delivery of fetus can lead to an infection. Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse. Another priority is assessment of amniotic fluid, which should be done once the membranes rupture. Amniotic fluid should be watery, clear, and have a slightly yellow tinge. Odor should not be foul and volume is between 700 and 1,000 mL. Immediately report any abnormal findings to provider. Try this practice question and provide a rationale for your response. A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following findings requires the nurse to follow-up?
- Frequency of every 2.5 minutes
- Duration 2 minutes or longer
- Intensity of 60 to 90 mm Hg with IUPC
- Resting tone of 15 mm Hg Answer 2 requires follow-up.
You previously learned about triage and discharging patients when beds are needed during a disaster. What type of patients could be discharged early in a disaster situation to free up beds in an acute care facility? In a mass casualty situation where beds are needed the most medically stable may be discharged early. Patients with acute conditions requiring treatment are not appropriate for discharge. Medically stable patients include observation patients not bedridden, patients admitted for diagnostic procedures, those scheduled for discharge soon, and patients that can be discharged with home health or family support. You learned about electronic fetal monitoring in the maternity course. A normal fetal heart rate (FHR) baseline at term is 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. Changes in FHR include accelerations and decelerations.
- Variable deceleration can indicate cord compression.
- Early decelerations can indicate fetal head compression.
- Persistent and consistent late decelerations with 50% or more of the contractions is suggestive of uteroplacental insufficiency. The first action of the nurse if fetal distress is noted: turn the mother to the side; start oxygen at 8 - 10 liters by mask. Increase the IV infusion; if indicated. If oxytocin is being administered, it should be turned down or off with fetal distress. Try this practice question from the NCLEX® Category: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care and provide a rationale for your response: A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, “I’ve had enough. I can’t do this anymore.” Which of the following stages of labor is the client experiencing?
- First stage
- Second stage
- Third stage
- Fourth stage Answer: 2
- The first stage of labor begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation. The client is more relaxed, talkative, and eager for labor to progress in the first stage.
- CORRECT: This is the second stage of labor. As noted in Chap 16 of the Maternal Child book the second stage of labor begins with full cervical dilation/complete effacement and ends with the baby’s birth. Signs that suggest onset of second stage include increased frequency and intensity of contractions, urge to push or feeling the need to have a BM, increased bloody show, an episode of vomiting, and verbalization of feeling out of control or unable to cope.
- The third stage of labor lasts from the birth of the baby until the placenta is expelled. This is the shortest stage of labor.
- The fourth stage of labor is the recovery period, which begins following the delivery of the placenta and lasts until the woman is stable in the immediate postpartum period. HHS is treated with fluids initially then insulin is added after fluid volume is replaced. Patients with Diabetes need education regarding exercise. In med/surg you learned about teaching for patients with Diabetes. What are important teaching points for patients with diabetes regarding exercise? See my maternity review in the faculty added content module. I recommend you review both videos with the slides included and have a good grasp of the information covered. Try this ATI practice question from NCLEX® Category: Health Promotion and Maintenance, Ante/Intra/Postpartum and Newborn Care. A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (Select all that apply)
- Lengthening of the umbilical cord
- Swift gush of clear amniotic fluid
- Softening of the lower uterine segment
- Appearance of dark blood from the vagina
- Fundus firm upon palpation Answer: 1, 4, and 5.
- CORRECT: The umbilical cord lengthens as the placenta is being expulsed.
- A sudden gush of clear amniotic fluid occurs when membranes rupture, which occurs prior to the third stage of labor. Expected findings with amniotic fluid are clear, the color of water, and free of odor. Abnormal findings should be reported, which include bloody fluid from vagina or the presence of meconium, abnormal color (yellow, green), and a foul odor.
irrigate with 50 mL irrigation solution using a large piston syringe or per facility or surgeon protocol. Contact the surgeon if unable to dislodge the clot. Record the amount of irrigating solution instilled (generally very large volumes) and the amount of return. The difference equals urine output. Avoid kinks in the tubing.
- Monitor vital signs and urinary output. Administer/provide increased fluids.
- Monitor for bleeding/hgb/hct. Report persistent bright-red bleeding unresponsive to increase in CBI or reduced Hgb/Hct levels.
- Assist the client to ambulate as soon as possible to reduce the risk of deep-vein thrombosis and other complications that occur due to immobility.
- Administer medications including Analgesics (surgical manipulation or incisional discomfort), Antispasmodics (bladder spasms), Antibiotics (prophylaxis), and Stool softeners (avoid straining). Teaching for discharge should include avoiding activities that increase intraabdominal pressure until the surgeon approves these activities at a follow-up visit. Teach the patient to avoid heavy lifting, climbing, and driving until the follow-up visit. Stool softeners and high-fiber diets may be used to promote bowel elimination, but enemas should not be used because they increase intraabdominal pressure and may initiate bleeding. Fluid intake should be high, but caffeine and alcohol should not be used because they have a diuretic effect and increase bladder distention. Because TURP does not remove the entire prostate gland, the patient needs annual prostatic examinations to screen for cancer of the prostate. You learned about Lithium, which is used in the treatment of bipolar disorders, in a previous class. Lithium controls episodes of acute mania and helps prevent the return of mania or depression. You mentioned lithium teaching needed in your post. What are specific teaching points would you provide for patients that are prescribed lithium? Teaching for patients prescribed lithium:
- Advise clients that effects begin within 7 to 14 days.
- Advise clients to take as prescribed. Lithium must be administered in 2 to 3 doses daily due to a short half- Taking lithium with food will help decrease GI distress.
- Lithium is Pregnancy Risk Category D. This medication is teratogenic, especially during the first trimester.
- Encourage clients to adhere to laboratory appointments needed to monitor lithium effectiveness and adverse effects. Emphasize the high risk of toxicity due to the narrow therapeutic range. Need to monitor CBC, serum electrolytes, renal function tests, and thyroid function tests during lithium therapy.
- Provide nutritional counseling. Stress the importance of adequate fluid and sodium intake. Encourage clients to maintain a diet adequate in sodium, and to drink 2,000 mL to 3,000 mL of water each day from food and beverage sources.
- Advise clients to observe for indications of toxicity and to notify the provider.
- Instruct clients to monitor for manifestations of toxicity and when to contact the provider. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating.
- Conditions that cause dehydration, such as exercising in hot weather or diarrhea, put client at risk for lithium toxicity and should be avoided. Patients with paranoid schizophrenia may experience alterations in thought (delusions). Assess the client for paranoid delusions, which can increase the risk for violence against others. If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others. When caring for patients with schizophrenia:
- Assess for paranoid delusions, which can increase the risk for violence against others.
- If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others
- Ask the client directly about hallucinations. Do not argue or agree with the client’s view of the situation.
- Appropriate comments by the nurse if the client is hallucinating would be “I don’t hear anything, but you seem to be feeling frightened.”
- Attempt to focus conversations on reality-based subjects.
- Provide prepackaged nutritious food because the client might not trust other food sources.
- Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations. Try this practice question and provide a rationale for your response. A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr?
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis Answer: 4
- Furosemide Answer: 2, 3, 4, and 5
- 45% sodium chloride is hypotonic. Clients who have acute adrenal insufficiency are hyponatremic. Anticipate a prescription for a solution that contains 0.9% sodium chloride.
- CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Insulin is administered to shift potassium into the cells.
- CORRECT: Hydrocortisone sodium is administered as replacement therapy for glucocorticoids.Fludrocortisone, a mineralocorticoid, is another medication that may be prescribed for adrenal hypofunction.
- CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Sodium polystyrenesulfonate (Kayexalate) may be prescribed because it absorbs and lowers potassium.
- CORRECT: Loop and thiazide diuretics promote potassium excretion and may be administered to treat hyperkalemia. Interventions to implement when caring for patients with acute adrenal insufficiency (Addisonian crisis) include:
- Monitor for hyperkalemia/dysrhythmias
- Monitor for hyponatremia/hypotension/confusion
- VS every 1-4 hours depending on patient condition
- Monitor for fluid depletion (postural hypotension and dehydration)
- Daily weights/I and O
- Monitor lab values for hemoconcentration Seizures are an abrupt, abnormal, excessive, and uncontrolled electrical discharge of neurons within the brain that can cause alterations in the level of consciousness and/or changes in motor and sensory ability and/or behavior. Epilepsy is the term used to define chronic recurring abnormal brain electrical activity resulting in two or more seizures. Seizures resulting from identifiable causes, such as substance withdrawal or fever, are not considered epilepsy. Try this practice question from NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration and include a rationale for your response. A nurse is preparing a teaching plan for a client who has a new prescription for carbamazepine. Which of the following instructions should the nurse include in the teaching? Select all that apply.
- “This medication can safely be taken during pregnancy.”
- “Eliminate grapefruit juice from your diet.”
- “You will need to have a complete blood count and carbamazepine levels drawn periodically.”
- “Notify your provider if you develop a rash.”
- “Avoid driving for the first few days after starting this medication.” Answer: 2, 3, 4, 5.
- Carbamazepine is a Pregnancy Category Risk D medication. The client should be instructed to avoid pregnancy while taking carbamazepine and to use a non-hormonal form of birth control as they may have a reduction in the efficacy of hormonal contraception.
- CORRECT: Grapefruit juice affects carbamazepine metabolism and should be avoided.
- CORRECT: Carbamazepine blood levels and the CBC should be monitored during therapy. The client is at risk for bone marrow depression while taking carbamazepine and should notify the provider for a sore throat or other manifestations of an infection.
- CORRECT: Carbamazepine can cause Stevens-Johnson syndrome, which can be fatal. The client should notify the provider promptly if a rash occurs.
- CORRECT: CNS effects (drowsiness or dizziness) can occur early in treatment with carbamazepine, and the client should avoid activities requiring alertness until these effects subside. Carbamazepine is not only prescribed as an anticonvulsant medication used to treat epilepsy, it is also used to treat neuropathic pain and schizophrenia (as a second-line agent in bipolar disorder). Most victims of elder abuse are frequently seen in the emergency department several times before they are admitted to the hospital. Nurses must be alert to any indications of elder abuse, such as suspicious injuries or behaviors, and report suspected incidents to local adult protective services agencies. Commons signs of elder abuse or maltreatment include the following:
- Bruises, cuts, burns, or broken bones that are unexplainable or suspiciously explained
- Malnourishment or weight loss
- Poor hygiene, an unkempt appearance, unclean clothing, or dirty, matted hair
- Foul odor from clothing or body
- Anxiety, depression, or confusion
- Unexplained transactions or loss of money
- Withdrawal from family members or friends Assessment is the initial priority when a patient presents with signs that could indicate abuse (adult or child) to determine how the injuries may have occurred.
Try this practice question and provide a rationale for your response: The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first? 1. Call a code immediately
- Assess the client for a pulse
- Begin chest compressions
- Continue to monitor the client Answer: 2. The nurse must first determine if the client has a pulse. Remember if the patient is in VFib or VTach without a pulse, this IS a shockable rhythm and the priority is to defibrillate. In a facility you should always locate the AED or crash cart before starting CPR. The nurse should call a code if the client does not have vital signs. Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia. Be sure you can recognize these shockable rhythms. Chest compressions (100 per minute with a ratio of 30:2 for compressions/breaths) are not the priority and are only done if the client is not breathing and has no pulse. vTach is a life- threatening dysrhythmia so continuing to monitor is not the priority. Pulseless ventricular tachycardia is treated as ventricular fibrillation. Remember it this way: A lways defib the v-fib! For a similar situation in the community, per CPR guidelines verify unresponsiveness, call for help, then check for breathing and pulse. If no pulse, then start compressions. Preserving forensic evidence is essential for investigative purposes following injuries that may be caused by criminal intent. The nurse should carefully document the client’s description of the incident and use quotes around the client’s exact words where possible. The documentation will become a part of the client’s record and can be subpoenaed for subsequent investigation. The nurse should not handle bullets from the client because they are an important piece of forensic evidence. Try this practice question and provide a rationale for your response : The nurse receives a male client from the post-anesthesia care unit (PACU) after the surgeon performed an abdominal repair related to trauma from a knife wound. After confirming patient identification, which assessment data would warrant immediate intervention by the nurse? a. VS T 97, P 108, R 24, BP 80/ b. Client is sleepy but opens eyes to verbal commands c. Client complains of pain level 7 on scale of 1- 10 d. 25 mL urine in urinary drainage bag
Answer: a. These VS indicate hypovolemic shock and require immediate intervention. Hypovolemic shock occurs secondary to rapid blood loss. Fluids are a priority with this BP. B is not correct as clients will be sleepy until the anesthesia wears off. C is not correct as pain is expected post-op and this is not a life-threatening complication. D is not correct as the bag would have been emptied by the PACU nurse prior to transferring client to the floor. Manifestations of alcohol withdrawal include:
- Abdominal cramping; vomiting; tremors; restlessness and inability to sleep; increased heart rate; transient hallucinations or illusions; anxiety; increased blood pressure, respiratory rate, and temperature; and tonic-clonic seizures.
- Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium.
- Alcohol withdrawal delirium can progress to death. Try this practice question and provide a rationale for your response: The RN is developing a standardized care plan for postoperative care of a client undergoing cardiac surgery. The RN has an LVN and UAP available for delegation of tasks. Which of the following needs to be performed by the RN?
- Changing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs.
- Reinforcing teaching about the need to deep breathe and cough at least every 2 hours while awake.
- Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes.
- Assisting the client to ambulate in the hall on the second post-op day. Answer 3 is correct. Development of the plan of care and initial teaching is the responsibility of the RN. LVNs can collect data for the care plan but the initial development for the patient plan of care is the responsibility of the RN. The RN is responsible for reviewing data collected when developing the plan of care.
