Download Nursing Care: A Guide to Common Conditions and Interventions and more Quizzes Nursing in PDF only on Docsity!
Postoperative Wound Care and
Infection Prevention
Wound Care Discharge Teaching
Recommendations for Wound Care
The nurse should instruct the family member to report any purulent (pus-like) drainage from the wound to the healthcare provider. This could be a sign of infection that requires medical attention. The nurse should not recommend irrigating the wound with povidone iodine or cleansing the wound with a cotton-tipped applicator, as these practices are not recommended for routine wound care. The nurse should not advise administering an analgesic (pain medication) following wound care, as this is not a typical recommendation. Pain management should be addressed separately based on the client's needs.
Bacterial Meningitis Assessment
Expected Findings
The nurse should expect to observe a red macular (flat, red) rash in a client with bacterial meningitis. This rash is a characteristic sign of the disease. The nurse should not expect to observe a flaccid (limp) neck, stooped posture with shuffling gait, or a masklike facial expression, as these are not typical findings in bacterial meningitis.
Osteoporosis Prevention
Recommended Interventions
The nurse should encourage the older adult client to engage in weight- bearing exercises, as this helps prevent bone loss and maintain bone density. The nurse should not recommend increasing fluid intake, range-of- motion exercises, or massaging bony prominences as interventions to prevent osteoporosis.
Skin Lesion Assessment
Identifying Potential Melanoma
The nurse should report irregular borders of a skin lesion as a possible sign of melanoma, as irregular borders are a concerning characteristic. The nurse should not report scaly patches, silvery white plaques, or raised edges as indicators of potential melanoma, as these findings are more suggestive of other skin conditions.
Dumping Syndrome Prevention
Dietary Recommendations
The nurse should advise the client to avoid liquids at mealtimes following a partial gastrectomy to prevent dumping syndrome. Consuming liquids with meals can exacerbate this condition. The nurse should not recommend excluding starchy vegetables, avoiding high-protein meals, or increasing intake of sweetened fruits, as these interventions are not typically part of the dietary management for dumping syndrome.
Pre-Cardiac Catheterization Assessment
Laboratory Values to Review
The nurse should review the client's blood urea nitrogen (BUN) level prior to the cardiac catheterization procedure, as this can provide information about the client's kidney function and potential risks associated with the procedure. The nurse should not focus on reviewing the client's albumin, phosphorus, or thyroid-stimulating hormone (TSH) levels, as these are not the primary laboratory values of concern for this procedure.
Glycosylated Hemoglobin (HbA1c) Testing
Client Understanding
The client demonstrates understanding of the HbA1c testing by stating that they will have the test checked twice per year. This frequency is recommended for monitoring glycemic control in individuals with diabetes. The client's statements about the HbA1c test being performed 2 hours after a high-carbohydrate meal, detecting ketones, or checking the test twice per year do not accurately reflect the purpose and timing of the HbA1c test.
Personal Protective Equipment for
Meningococcal Pneumonia
Appropriate PPE
The nurse should use a mask when caring for a client with meningococcal pneumonia to prevent the transmission of respiratory droplets. The nurse should not need to use a gown, sterile gloves, or protective eyewear as the primary personal protective equipment for this condition.
Gastroesophageal Reflux Disease (GERD)
Management
Recommended Lifestyle Modifications
The nurse should instruct the client to wait at least 2 hours after eating before going to bed, as this can help prevent reflux episodes. The nurse should not recommend eating three meals a day without snacks, seasoning food with garlic, or drinking liquids through a straw as part of the teaching for GERD management.
Epidural Infusion Monitoring
Priority Finding
The nurse should recognize dyspnea (difficulty breathing) as the priority finding when caring for a client with an epidural infusion, as this could indicate a serious complication. The nurse should not prioritize pruritis (itching), nausea, or urinary retention as the primary concern, as these are less urgent complications of epidural analgesia.
Insulin Glargine Teaching
Key Information
The nurse should instruct the client that insulin glargine should be given at the same time every day, as this is an important aspect of the medication's administration. The nurse should not advise the client that insulin glargine can be mixed with short-acting insulin or used in an insulin pump, as these statements are not accurate for this specific insulin type.
Testicular Self-Examination Teaching
Appropriate Client Understanding
The client demonstrates understanding that testicular cancer is painless, which is an important aspect of testicular self-examination teaching. The client's statements about checking their testicles every 6 months or that pea-sized lumps are normal do not accurately reflect the appropriate teaching for testicular self-examination.
Preoperative Anxiety Management
Priority Intervention
The nurse should prioritize determining the client's understanding of the upcoming surgical procedure, as this can help identify and address any misconceptions or concerns the client may have. The nurse should not prioritize encouraging the client to express feelings, allowing the client's family to stay, or providing music as a distraction, as these are not the most important initial interventions for managing preoperative anxiety.
Barriers to Learning in Knee Arthroplasty
Discharge Teaching
Identifying a Potential Barrier
The nurse should identify the client stopping the nurse and asking for pain medication as a potential barrier to learning, as this may indicate the client is focused on their immediate needs rather than absorbing the discharge instructions. The client asking questions, referring to written materials, or having a family member ask for clarification do not necessarily indicate a barrier to learning in this context.
Hip Arthroplasty Discharge Instructions
Appropriate Recommendations
The nurse should instruct the client to avoid bending their hips more than 90 degrees, as this is a common precaution following a hip arthroplasty. The nurse should not recommend crossing the legs, lying on the operative side, or sleeping on a soft mattress, as these would not be appropriate instructions for this client.
Peripheral Vascular Disease Management
Adherence to Nurse's Instructions
The client's statement about wearing clean, knee-high wool socks daily to improve circulation indicates they are adhering to the nurse's instructions for managing peripheral vascular disease. Applying rubbing alcohol, using hot water bottles, or other inappropriate self-care measures would not demonstrate adherence to the nurse's recommendations.
Pre-CT Scan Laboratory Review
Reporting Concerning Findings
The nurse should report an elevated creatinine level of 1.9 to the provider prior to the client's CT scan with IV contrast, as this could indicate impaired kidney function and increased risk of contrast- induced nephropathy. The nurse should not need to report the client's sodium, potassium, or calcium levels as concerning findings prior to this procedure.
MRSA Wound Infection Visitor Instructions
Appropriate Precautions
The nurse should instruct visitors to don a gown and gloves prior to entering the client's room to prevent the transmission of the MRSA infection. The nurse should not recommend that visitors call prior to visiting, wear a mask, or avoid bringing fresh flowers, as these are not the primary infection control measures for this situation.
Dietary Fat Recommendations for
Cardiovascular Disease
Appropriate Cooking Fat
The nurse should recommend that the client use olive oil when preparing meals, as this is a healthier unsaturated fat that is beneficial for cardiovascular health. Butter, coconut oil, and shortening are not the optimal cooking fats the nurse should recommend for this client with cardiovascular disease.
Hydrochlorothiazide Side Effect Monitoring
Reportable Finding
The nurse should instruct the client to report the onset of nausea, as this could be an adverse effect of the hydrochlorothiazide medication. Increased urinary output, weight loss, or missed doses are not the primary side effects the client should be advised to report to the provider.
Tracheostomy Suctioning Procedure
Appropriate First Step
The nurse should first ventilate the client with 100% oxygen before suctioning the tracheostomy, as this helps ensure adequate oxygenation. Inserting the suction catheter, rinsing the catheter, or occluding the vent are not the appropriate first steps in the tracheostomy suctioning procedure.
Low-Sodium Diet Taste Recommendations
Appropriate Seasoning
The nurse should recommend that the client use lemon juice to improve the taste of bland low-sodium foods, as this can add flavor without increasing sodium content. Ketchup, mayonnaise, and soy sauce are not appropriate recommendations for a client on a low-sodium diet, as they are high in sodium.
Morphine Medication Review
Reportable Finding
The nurse should report the client's urinary retention to the provider, as this could be an adverse effect of the morphine medication. The administration of celecoxib, history of immunosuppression, or administration of levothyroxine are not the primary concerns the nurse should report regarding the client's morphine prescription.
pulmonary embolism, which is a serious complication that can occur after surgery.
Immobilization Complications
Lack of Sensation Between Toes
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. The nurse should recognize that a lack of sensation between the first and second toes is an abnormal finding, which may indicate a complication such as nerve damage or impaired circulation due to the cast.
Cancer and Birth Control
Contraindicated Birth Control Method
A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. The nurse should recognize that combination oral contraceptives are contraindicated for this client, as they may increase the risk of cancer recurrence.
Medication Effects
Decreased Shortness of Breath
A nurse is collecting data from a client who has heart failure and is taking digoxin. The nurse should expect that a decreased shortness of breath is a desired outcome of the medication, as it can help improve the client's heart function and reduce symptoms of heart failure.
Avoiding Sudden Medication Discontinuation
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. The nurse should include the instruction to avoid stopping this medication suddenly, as sudden discontinuation can lead to withdrawal symptoms and potentially worsen the client's condition.
Delayed Wound Healing
A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus should identify that a prealbumin level of 12 mg/dL indicates the client is at risk for delayed wound healing. Prealbumin is a marker of protein status, and low levels can impair the body's ability to heal wounds effectively.
Postoperative Care
Obtaining a Raised Toilet Seat
A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. The nurse should include the instruction to obtain a raised toilet seat, as this can help the client maintain proper hip precautions and prevent dislocation of the prosthetic joint.
Preventing Aspiration During NG Tube Movement
A nurse is preparing to move a client's NG tube. The nurse should pinch the NG tube to prevent aspiration, as this action helps to maintain the tube's position and prevent the contents from flowing back into the client's throat.
Electrolyte Imbalances
Bradycardia and Hyperkalemia
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. The nurse should expect to find bradycardia as a finding related to hyperkalemia, as elevated potassium levels can disrupt the heart's electrical conduction and lead to slow heart rates.
Inhaler Use
Proper Inhaler Technique
A nurse is reinforcing teaching with a client who has asthma. The client statements that indicate an understanding of the proper use of budesonide and albuterol inhalers are: "I never forget to rinse my mouth after using my budesonide inhaler" and "Between office visits, I keep a record of how many times I use my albuterol inhaler".
Allergic Reaction Management
Administering Epinephrine
A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing, indicating an anaphylactic reaction. After establishing a patent airway, the nurse should administer epinephrine, as this is the first-line treatment for a severe allergic reaction.
Hormone Replacement Therapy
Contraindication to HRT
A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes and is interested in trying hormone replacement therapy (HRT). The nurse should recognize that a history of treatment for blood clots is a contraindication to HRT, as it can increase the risk of thromboembolic events.
Cancer Treatment
Mohs Surgery Description
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. The nurse should include the information that Mohs surgery is a horizontal shaving of thin layers of the tumor, as this accurately describes the technique used in this surgical procedure.
Skin Care
Minimizing Head of Bed Elevation
A nurse is caring for an older adult client who has a reddened area over the sacrum. The nurse should take the action of minimizing the time the head of the bed is elevated, as this can help reduce pressure on the sacral area and prevent the development of a pressure injury.
Maintaining Dry Skin
A nurse is caring for a client who is in Buck's traction. To reduce the risk of skin breakdown, the nurse should keep the skin dry and free of perspiration, as moisture can contribute to skin irritation and breakdown.
Infection Control
Designated Equipment
A nurse is contributing to the plan of care for a client who has a methicillin- resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. The nurse should have a designated stethoscope in the client's room, as this helps prevent the spread of the infection to other clients and healthcare providers.
Medication Effects
Pain Reduction
A nurse is caring for a client who has a prescription for phenazopyridine. The nurse should identify that a therapeutic effect of the medication is decreasing pain during urination, as this is the primary mechanism of action for this urinary analgesic.
Sodium Restriction
A nurse is reinforcing discharge teaching with a client who has cirrhosis. The nurse should include the instruction to consume foods low in sodium, as clients with cirrhosis often require a sodium-restricted diet to help manage fluid retention and other complications of the disease.
Infection Precautions
Masking the Client During Transport
A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. The nurse should include the intervention of applying a mask on the client if transport is needed, as this helps prevent the spread of the infection to others.
Sleep Promotion
Getting Out of Bed if Unable to Sleep
A nurse is assisting a client who reports difficulty falling asleep. The nurse should recommend that the client get out of bed if unable to fall asleep within 60 minutes, as this can help promote sleep by breaking the cycle of frustration and anxiety associated with being unable to sleep.
Nursing Interventions for Stroke Patients
Reducing the Risk of Aspiration
To reduce the risk of aspiration in a client who has an acute ischemic stroke 1 day ago, the nurse should:
Provide a straw for drinking liquids. This allows the client to drink liquids without tilting the head back, reducing the risk of aspiration. Serve foods at room temperature. Serving foods at room temperature can make them easier to swallow and reduce the risk of aspiration. Place 2 tsp of food in the client's mouth at a time. Providing smaller portions of food at a time can help the client manage the food more effectively and reduce the risk of aspiration.
"Your partner will require treatment for this infection." Gonorrhea is a sexually transmitted infection, and the client's partner(s) should also be treated to prevent reinfection. "You can resume sexual activity as soon as you begin treatment." This is not appropriate advice, as the client should abstain from sexual activity until the infection is fully treated and resolved. "You will not be at further risk for this infection following treatment." This is not accurate, as the client can be reinfected with gonorrhea if exposed again.
Bowel Retraining for Spinal Cord Injury
When assisting in the plan of care for bowel retraining for a client with a cervical spinal cord injury, the nurse should first:
Determine the client's daily elimination habits. This is the essential first step to understand the client's baseline bowel patterns and guide the development of an appropriate bowel retraining program.
The nurse should then plan to implement the following interventions:
Administer a suppository to the client 30 minutes prior to defecation time. Offer the client 4 oz of warm prune juice to promote elimination. Provide dietary bulk to the client to ease the passage of stool.
Prioritizing Interventions for Stroke Patients
When contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hours ago, the nurse should identify the following intervention as the priority:
Maintain the client's body alignment. Keeping the client in a side-lying position helps maintain proper body alignment and prevent complications.
The nurse should also:
Encourage the client to participate in self-care activities as tolerated. Assist the client with active range-of-motion exercises to prevent contractures and maintain joint mobility.
Administering Furosemide
Before administering furosemide to a client with heart failure, the nurse should report the following finding to the provider:
Decreased potassium. Furosemide is a diuretic that can cause potassium depletion, and this electrolyte imbalance should be addressed before administering the medication.
The nurse should not report elevated sodium, elevated blood pressure, or decreased urine output, as these are not contraindications to administering furosemide.
Managing Tonic-Clonic Seizures
When observing a client experiencing a tonic-clonic seizure, the nurse should take the following action:
Loosen clothing around the client's neck. This helps ensure the client's airway is not obstructed during the seizure.
The nurse should not:
Lower the side rails of the client's bed, as this could increase the risk of injury. Apply wrist restraints to the client, as this is not an appropriate intervention for a seizure. Position the client in the semi-Fowler's position, as this could interfere with the client's breathing during the seizure.
Joint Protection for Rheumatoid Arthritis
When reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis, the nurse should include the following information:
Apply cold packs to the inflamed joints. This can help reduce pain and inflammation. Carry a hand purse rather than a shoulder bag. This helps avoid putting stress on the shoulder joints. Sleep on a soft foam mattress. This can provide comfort and support for the joints.
The nurse should not recommend that the client participate in high-impact exercise, as this could further aggravate the client's condition.
Immunizations for Older Adults
When recommending immunizations for older adult clients at a health fair, the nurse should suggest the following:
Herpes zoster (shingles) vaccine. This is recommended for older adults to prevent shingles, a common and potentially serious condition in this age group.
The nurse should not recommend the meningococcal, human papillomavirus (HPV), or measles, mumps, and rubella (MMR) vaccines, as these are not the primary immunizations indicated for older adults.
Weight loss
Health Screening Guidelines for Older Adults
When discussing health screening guidelines with an older adult client, the nurse should include the following statement:
"You should have a pneumococcal immunization every 10 years." This is a recommended vaccination for older adults to prevent pneumococcal infections.
The nurse should not state:
"You should have a screening for glaucoma every 5 years." This is not a standard screening recommendation for older adults. "You should have a physical examination every other year." The frequency of physical examinations for older adults may vary based on individual health status and provider recommendations.
Responding to IV Complications
When assisting a client who is experiencing pain and swelling at the IV site during a continuous 0.9% sodium chloride infusion, the nurse should perform the following steps in order:
Check the IV site. Stop the infusion. Withdraw the IV catheter. Notify the charge nurse.
Caring for Clients with Total Knee
Arthroplasty
When contributing to the plan of care for a client who is postoperative following a total knee arthroplasty and using a continuous passive motion (CPM) machine, the nurse should recommend the following intervention:
Keep a sheepskin pad between the client's extremity and the CPM. This helps prevent skin irritation and pressure ulcers.
The nurse should not recommend:
Storing the CPM machine on the floor when not in use, as this could compromise the integrity of the device. Checking the cycle and range-of-motion settings at least every 12 hours, as this is not a necessary intervention. Aligning the frame joint of the CPM with the middle of the client's calf, as the proper alignment may vary based on the client's anatomy and the specific CPM device.
Manifestations of Acute Pancreatitis
When caring for a client with acute pancreatitis and observing ecchymosis around the umbilicus, the nurse should identify this as a manifestation of intra-abdominal bleeding, also known as Cullen's sign.
Addressing Appetite Changes During
Chemotherapy
When caring for a client who is receiving chemotherapy and experiencing a loss of appetite due to mouth sores and altered taste, the nurse should suggest the following:
Eat several, small-portioned meals daily. This can help the client consume adequate nutrition despite the decreased appetite.
The nurse should not recommend:
Drinking water before and after each bite, as this is not an effective strategy for managing appetite changes. Consuming foods that are served hot rather than cold, as temperature preference may vary based on the client's individual preferences. Rinsing with a glycerin-based mouthwash before meals, as this is not an appropriate intervention for addressing the client's appetite concerns.
Interventions for Post-Stroke Eating
Difficulties
When contributing to the plan of care for a client who is having difficulty eating following a stroke, the nurse should first:
Recommend a referral for a speech language pathologist. This specialist can assess the client's swallowing function and provide appropriate recommendations for safe and effective feeding.
The nurse should then plan to implement the following interventions:
Collaborate with a dietitian to ensure the client's nutritional needs are met. Provide nutritional supplements as needed to support adequate intake. Inform assistive personnel about proper positioning during meals to facilitate safe swallowing.
