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Nursing Interventions for Diverse
Client Scenarios
Nursing Assessment and Interventions
Left-Sided Heart Failure
Nurse should expect the following findings when assessing a client with left-sided heart failure: Tachycardia (not bradycardia) due to the failing left ventricle, which activates the sympathetic nervous system Flushed, dusky skin appearance Frothy, blood-tinged sputum Other expected findings include: Dyspnea, orthopnea (shortness of breath while lying down), and nocturnal dyspnea Displaced apical pulse and S3 heart sound (gallop rhythm) Fatigue, pulmonary congestion with bibasilar crackles Altered mental status Oliguria (decreased urine output)
Renal Colic
When a client is experiencing renal colic from a calculus in the left renal pelvis, the nurse should expect the client to have referred pain in the inguinal area and lower back. Renal colic occurs in the kidney area, but the pain can be referred to other locations.
Peritoneal Dialysis
If the nurse notes a decrease in the dialysate flow rate for a client receiving peritoneal dialysis, the nurse should: - Monitor the access site for drainage (to check for signs of infection) - Measure the amount of the dialysate outflow - Position the client in a supine position (not raise to high Fowler's or position to the other side)
Indwelling Catheter Insertion
When inserting an indwelling catheter for a female client, the nurse should:
- Collect the urine specimen from the drainage bag, not the port, as urine in the bag for more than 1 hour is contaminated - Position the client in the dorsal recumbent position (flat with legs spread wide), not raise the head of the bed to 45 degrees - Secure the catheter to the client's inner thigh, not attach the bag to the bed rail
Age-Related Macular Degeneration
When providing teaching to a client with age-related macular degeneration, the nurse should include the following information: - The client has a central loss of vision affecting the macula of the eye, not a retinal detachment - The client has likely noticed a decline in their central vision, not a general decline in vision - There is no surgical correction for the folds in the retina, as there is no cure for macular degeneration
Cirrhosis
When assessing a client with cirrhosis, the priority finding for the nurse to report is: - Platelets 70,000/mm3, as this low platelet count increases the risk of bleeding (the normal range is 150,000-300,000/mm3) - The distended abdomen and clay-colored stools are expected findings in cirrhosis
Total Parenteral Nutrition (TPN) Discontinuation
When discontinuing long-term TPN therapy, the nurse should plan to do so gradually to reduce the risk of hypoglycemia, not hyperglycemia. Abruptly discontinuing TPN can cause rebound hypoglycemia as the body adjusts to producing its own insulin again.
Packed Red Blood Cell (PRBC) Transfusion
When administering a unit of packed RBCs, the nurse should: - Administer the unit over 2-4 hours, not 1 hour - Obtain the client's first set of vital signs within the first 15-30 minutes of initiating the transfusion, not 1 hour after - Initiate venous access with an 18- or 20-gauge needle, not a 21-gauge needle
Fluticasone Inhaler for COPD
When providing discharge teaching to an older adult client with COPD who is starting fluticasone by metered-dose inhaler, the nurse should include the instruction to: - Obtain a yearly influenza immunization to reduce the risk of infection, not limit fluid intake or use fluticasone as needed
Total Hip Arthroplasty Discharge Teaching
When providing discharge teaching to an older adult client following a left total hip arthroplasty, the nurse should include the instructions to: - Avoid crossing the legs at the ankles when sitting down - Install a raised toilet seat in the bathroom - Use an incentive spirometer every hour, not every 8 hours
Postoperative Femur Fracture Findings
For a client who is postoperative following a femur fracture, the nurse should immediately report the following finding to the provider: - The client reports shortness of breath, as this may indicate a pulmonary embolism
Lisinopril and Medication Interactions
When caring for a client with hypertension who is starting lisinopril, the nurse should consult the provider about any medications containing aliskiren, as these can interact with lisinopril and cause hyperkalemia.
Post-Cholecystectomy Interventions
For a client 1 day post-open cholecystectomy, the nurse should include the following interventions in the plan of care: - Apply compression stockings to the lower extremities - Encourage leg exercises while in bed to prevent stasis - Avoid the use of anticoagulants
Warfarin Therapy Interactions
Substances that can interfere with warfarin therapy include: - Potatoes (high in potassium) - Oranges (high in vitamin C) - Cauliflower (high in vitamin K)
Furosemide Effectiveness
For a client receiving furosemide 80 mg for pulmonary edema, an indication that the medication is effective is a weight loss of 1.8 kg (4 lb) in the past 24 hours, not an elevation in blood pressure or a respiratory rate of 24/min.
Cushing's Disease Findings
When caring for a client with Cushing's disease, the nurse should expect to find: - Hyperglycemia - Hypokalemia and hypocalcemia - Not weight loss, as Cushing's disease is associated with weight gain
Hemolytic Transfusion Reaction
Manifestations that indicate a hemolytic transfusion reaction include: - Low back pain - Tachycardia - Hypotension - Not bradycardia or hypertension
Postoperative Nasogastric Tube Drainage
In the first postoperative hour following abdominal surgery, the nurse should report to the provider: - 100 mL of red (sanguineous/fresh bleeding) drainage from the NG tube
Elaboration of the Given Text
Rationale: Expected Findings in Chronic Kidney Disease
(CKD)
In most cases of chronic CKD, the expected findings are related to fluid overload, including both hypertension (HTN) and orthostatic hypotension.
Notable examples or evidence provided in the text include nausea, fatigue, lethargy, involuntary movement of legs, depression, and intractable hiccups.
Hypothyroidism Teaching
When teaching a client with hypothyroidism, the nurse should include the following information:
A. The client will need to take medication for this condition for several months. B. The client may need to eat a high-fiber diet to prevent complications of this condition. C. The client might notice that they perspire less with this condition (not more, as in hyperthyroidism). D. The nurse will perform laboratory tests to monitor the effect of the client's medication. E. This condition can cause the client to gain weight.
Low Pressure Alarm on Mechanical Ventilator
When the low pressure alarm sounds on the ventilator, the nurse should take the following action:
B. Evaluate the client for a cuff leak and check this first for the cause of the low pressure.
Reporting Laboratory Values to the Surgeon
The nurse should report the following laboratory values to the surgeon:
a. INR of 1.6 (Normal 1.0-2.0) b. Hct 42% (Normal 42%-52% men; 37%-47% women) d. WBC 8,000/mm3 (Normal 5,000-10,000/mm3)
Effectiveness of Valsartan for Heart Failure
The nurse should identify the following finding as an indication that the medication (valsartan) is effective:
b. Decreased blood pressure
Positioning After a Liver Biopsy
The nurse should instruct the client to lie on the right lateral position with the patient bed flat for a minimum of 2 hours after the liver biopsy procedure.
Discharge Teaching After a Modified Left Radical
Mastectomy with Breast Expander
The statement by the client that indicates an understanding of the teaching is:
a. "I will have to wait 2 months before additional saline can be added to my breast expander."
a. Do not attempt to reinsert the protruding viscera. b. Obtain bottles of warm, sterile 0.9% sodium chloride solution to cover the wound with a sterile saline-soaked towel or dressing.
Client at Risk for Developing Metabolic Alkalosis
The client who is receiving continuous gastric suctioning is at risk for developing metabolic alkalosis.
Electrolyte Imbalance that Can Increase the Risk for
Digoxin Toxicity
The electrolyte imbalance that can increase the risk for digoxin toxicity is a decrease in potassium level.
Findings to Report to the Provider After a Colon Resection
The nurse should report the following finding to the provider:
a. Erythema (redness) of the abdominal wound, as it can be indicative of infection.
Medication Prescription Based on Admission Assessment
Based on the provided vital signs (Temperature 98.3°F, HR 100/min, RR 20/ min, BP 152/94 mmHg), the provider is likely to prescribe metoprolol.
Respiratory Pattern Indicating Increased Intracranial
Pressure
The respiratory pattern that indicates increased intracranial pressure is Cheyne-Stokes respirations, which is characterized by alternating periods of rapid breathing and apnea.
Action for Small Clots in the IV Bag During Blood
Transfusion
The nurse should take the following action:
c. Return the unit of packed RBCs to the blood bank.
Instructions for Self-Management of GERD
The nurse should include the following instruction in the teaching:
d. "Sleep with the head of your bed elevated 6 inches" to prevent acid from reaching the throat.
Earliest Indication of Peritonitis During Peritoneal Dialysis
The earliest indication of peritonitis is a rigid, board-like abdomen.
Intervention to Prevent Aspiration During Enteral
Nutrition
The nurse should measure the residual volume prior to bolus feedings to prevent aspiration.
Pressure Ulcer Assessment
The findings for the pressure ulcer are: - Wound tissue firm to palpation (firm, not healing yet) - stage 1 - Dry brown eschar (dead skin) - Dark red granulation tissue
Steps for Using a Peak Flow Meter
The steps for using a peak flow meter are: 1. Stand upright 2. Fill your lungs with a deep breath 3. Seal your lips around the mouthpiece 4. Blast the air out as hard and as fast as possible in a single blow 5. Record the highest of three consecutive readings
Care for a Client with an External Fixator
The nurse should take the following actions: - Maintain the affected extremity in an elevated position - Palpate the dorsalis pedis pulse - Wrap sterile gauze on the sharp points of the pins every 8-12 hours
Instructions for Using an Automated External Defibrillator
(AED)
The nurse should include the following instructions in the teaching: - Position the client on a flat surface - Set the AED to 200 joules - Do not use an AED for a client who has atrial fibrillation (AED is for ventricular fibrillation and ventricular tachycardia)
Serum Sodium Level and Associated Findings
Hyponatremia (Serum Sodium Level of 120 mEq/L)
The nurse should expect the following findings in a patient with a serum sodium level of 120 mEq/L, which indicates hyponatremia:
Decreased bowel sounds - increased motility Abdominal cramping Nausea Weakness Lethargy Confusion
Once you are able to get out of bed safely, take frequent walks and continue practicing the cough.
The rationale is that the use of the incentive spirometer promotes lung expansion and helps prevent atelectasis and other respiratory complications.
Multiple Organ Dysfunction Syndrome
(MODS) in Septic Shock
In a patient with septic shock, the following lab findings would indicate the development of multiple organ dysfunction syndrome (MODS):
Arterial hypoxemia (low or no oxygen delivery to tissues) Hypoglycemia (the body's response to try to save energy)
The rationale is that severe hypotension and reperfusion of ischemic cells can lead to further tissue injury, causing organ failure in the lungs (adult respiratory distress syndrome), kidneys, heart (decreased coronary artery perfusion and decreased cardiac contractility), and the gastrointestinal tract (necrosis).
Hypokalemia (Potassium Level of 2.8 mEq/L)
The nurse should expect the following findings in a patient with a potassium level of 2.8 mEq/L, which indicates hypokalemia:
Hypoactive bowel sounds Hypotension Decreased reflexes (not exaggerated reflexes)
The manifestations of hypokalemia include irregular pulse, muscle weakness and cramping, fatigue, nausea, vomiting, irritability, confusion, decreased bowel sounds, paresthesia, dysrhythmias, and flat or inverted T waves on the ECG.
Nursing Interventions for a Client with a
Seizure Disorder
The nurse should include the following interventions in the plan of care for a client with a seizure disorder:
Do not attempt to restrain the client during a seizure. Keep the side rails up with padding to prevent injury. Do not use a padded tongue blade, as this can cause injury. Maintain peripheral IV access to administer emergency medications like diazepam, lorazepam, or phenytoin if needed.
The rationale is to protect the client from injury during a seizure and maintain access for emergency medication administration if necessary.
Medication Considerations for an Older Adult
Client
The nurse should report the following finding to the provider for an older adult client with hypertension who has a new prescription for nadolol:
Asthma
The rationale is that beta-blockers like nadolol can cause bronchoconstriction and should be avoided in clients with asthma.
Positioning for a Lumbar Puncture
The nurse should assess the client in the fetal position or sitting forward on the table for a lumbar puncture procedure.
Acid-Base Imbalance in Diabetic Ketoacidosis
Based on the given ABG values (pH 7.14, PaO2 90 mmHg, PaCO2 35 mmHg, HCO3- 4 mEq/L), the nurse should identify that the client has metabolic acidosis.
The rationale is that the low pH, low HCO3-, and compensating low PaCO indicate a metabolic acidosis.
Dietary Recommendations for Nephrotic
Syndrome
The nurse should include the following dietary recommendations in the plan of care for a client with nephrotic syndrome:
Decrease protein intake Increase carbohydrate intake Avoid excess sodium
The rationale is that nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, so the goal is to minimize protein intake, increase carbohydrates, and avoid excess sodium to prevent further fluid retention.
Interventions for Acute Pancreatitis
The nurse should include the following interventions in the plan of care for a client with a new diagnosis of acute pancreatitis:
Maintain the client on NPO (nothing by mouth) status until the pain is resolved. Place the client in the supine position.
Medication for Diabetes Insipidus
The nurse should expect to administer desmopressin acetate (an antidiuretic hormone) to a client with diabetes insipidus who has a urine output of 3, ml in the past 12 hours.
The rationale is that diabetes insipidus is characterized by a deficiency of antidiuretic hormone (ADH), leading to polyuria, polydipsia, and polyphagia. Desmopressin, a synthetic ADH, is used to manage the polyuria and prevent dehydration.
Findings Requiring Further Assessment After
Pacemaker Placement
The nurse should further assess the client if they experience hiccups after the placement of a permanent pacemaker.
The rationale is that hiccups can indicate that the pacemaker generator is pacing the diaphragm, which requires further assessment and potential adjustment of the pacemaker settings.
Calculating Protein Requirements for Total
Parenteral Nutrition (TPN)
To calculate the appropriate protein intake for a client receiving TPN who weighs 160 lb, the nurse should use the following steps:
Convert the client's weight from pounds to kilograms: 160 lb / 2.2 = 72.72 kg The recommended daily allowance (RDA) of protein is 0.8 g/kg of body weight. Multiply the client's weight in kg by the RDA of 0.8 g/kg: 72.72 kg x 0. g/kg = 58 g of protein.
Assessing Adequate Circulation of an
Arteriovenous Graft
The nurse should assess for a palpable thrill (a vibrating sensation) in the arterial and venous portions of the graft to indicate adequate circulation and patency of the arteriovenous graft.
The absence of a bruit (a sound heard with a stethoscope) does not necessarily indicate inadequate circulation.
Discharge Teaching for Genital Herpes
The nurse should ensure the client understands the following regarding the treatment of genital herpes:
The lesions should be expected to resolve in 2-4 weeks, not 6 weeks. The client should take the antiviral medication (e.g., acyclovir) for the prescribed duration, not for 3 weeks. The client should use condoms made of latex, not "natural skin" condoms, during sexual activity. The client should not apply antibiotic ointment to the lesions, as antiviral medication is the appropriate treatment.
Medication Administration Prior to
Chemotherapy
The nurse should administer ondansetron, a serotonin blocker, prior to chemotherapy to help prevent nausea and vomiting.
Serotonin blockers, often administered with corticosteroids, phenothiazines, and antihistamines, have been found to be effective in managing chemotherapy-induced nausea and vomiting.
Withholding Medication Before Contrast Dye
Procedure
The nurse should withhold metformin for 24 hours before the client undergoes a procedure that requires IV contrast dye.
The rationale is that the use of contrast dye with iodine increases the risk of lactic acidosis in clients taking metformin.
Central Venous Catheter Insertion in a
Malnourished Client
When assisting with the insertion of a non-tunneled central venous catheter for a malnourished client, the nurse should:
Confirm the correct position of the line by obtaining a blood sample. Cleanse the site with a chlorhexidine solution, not hydrogen peroxide. Place the client in the Trendelenburg position or supine position, not with the head of the bed lower than the foot.
The rationale is that the Trendelenburg or supine position helps increase pressure in the central veins, and chlorhexidine is the recommended antiseptic for central line insertion.
Nurse's Expectations
The client reports loss of peripheral vision. The client's eyes are watery. The client's pupils are constricted. The client reports dark floaters in the affected eye.
Care for a Client with Left-Sided Hemiplegia
Following a Stroke
Remind the client to use a cane on the unaffected (right) side while ambulating. Provide the client with a long-handled reacher. Position the bedside table on the client's unaffected (right) side. Place a plate guard on the client's meal tray.
Flushing an Implanted Port for Chemotherapy
The nurse should plan to use a noncoring (Huber) needle to access the implanted port.
Dietary Teaching for a Client with Heart
Failure
The client's understanding of the teaching is indicated by the following statements:
"I can have mayonnaise on my sandwiches." (Incorrect, mayonnaise is high in sodium) "I can drink vegetable juice with a meal." (Correct, vegetable juice is low in sodium) "I can season my foods with garlic and onion salts." (Incorrect, garlic and onion salts are high in sodium) "I can have a frozen fruit juice bar for dessert." (Correct, frozen fruit juice bars are low in sodium)
Evaluation for Bacterial Meningitis
The nurse should gently elevate the client's head and note any nuchal rigidity as part of the focused assessment.
Postoperative Findings Following a Colon
Resection
The nurse should report a heart rate of 90 bpm to the surgeon, as it may indicate a possible hemorrhage.
Medication for Diabetes Insipidus
The nurse should plan to administer desmopressin, as it increases antidiuretic hormone (ADH) and helps stop the patient from urinating excessively.
Monitoring for a Client Taking Ibuprofen
The nurse should monitor the client's stool for occult blood, as ibuprofen (an NSAID) can cause gastrointestinal bleeding.
Breakthrough Pain Management for a Client
with Cancer
The nurse should anticipate a prescription for a short-acting opioid medication, such as morphine sulfate or fentanyl, to treat the client's breakthrough pain.
Electrocardiogram Findings Indicating
Myocardial Infarction
The nurse should analyze the ST segment elevation on the ECG to determine if the client is experiencing a myocardial infarction.
Skin Care Following Radiation Treatment for
Ovarian Cancer
The nurse should instruct the client to pat the skin on the radiation site to dry it and avoid using a washcloth or applying moisturizer to the radiation site.
Medication Administration During a Blood
Transfusion
The nurse should anticipate administering a diuretic, such as furosemide, to the client who is experiencing bounding peripheral pulses, hypertension, and distended jugular veins, as these signs may indicate fluid retention or heart failure.
Effectiveness of Magnesium Sulfate
Administration
The nurse should assess the client's lungs to ensure they are clear, as this indicates the effectiveness of the magnesium sulfate administration for the treatment of hypomagnesemia.
showering, and cover the dressing to avoid water exposure - Use a 10 mL syringe when flushing the catheter
Reporting Findings for a Client with a Central
Venous Access Device
The nurse should report the following findings to the provider: - Elevated white blood cell count (16,000/mm³), as it may indicate infection - Increased body temperature, as it may also indicate infection
Dietary Teaching for a Client with Chronic
Kidney Disease
The client's understanding of the teaching is indicated by the following statements: - "I will spread my protein allowances over the entire day." (Correct) - "I should increase my intake of canned salmon to three times per week." (Incorrect, canned salmon is high in sodium) - "I will season my food with lemon pepper rather than salt." (Correct, avoiding added salt is important)
Dietary Considerations for Chronic Kidney
Disease (CKD)
Sodium, Potassium, Phosphorus, and Magnesium Intake
The text indicates that the nurse should limit the client's intake of sodium, potassium, phosphorus, and magnesium, as these are important considerations for clients with CKD. The rationale provided is that restricting these electrolytes can help prevent fluid retention and hypertension, which are common complications in CKD.
Cheese Intake
The nurse should limit the client's intake of hard cheese to 3 ounces per day to avoid excessive sodium intake. The rationale is that clients with CKD need to control their protein intake based on the stage of CKD and type of dialysis.
Peripherally Inserted Central Catheter (PICC)
Care
Flushing the PICC Line
The nurse should flush the PICC line with 10 mL of 0.9% sodium chloride solution after each dose of medication, not 20 mL as stated in the text. The rationale is that a 10 mL flush is the appropriate volume to maintain catheter patency.
Dressing Changes
The transparent dressing on the PICC line can be changed every 7 days, not daily as stated in the text. The rationale is that the dressing can remain in place for up to 7 days, as long as it remains clean and dry.
Metered-Dose Inhaler (MDI) Administration
Inhaler Preparation
The nurse should instruct the client to shake the inhaler 5-6 times before use, not to avoid shaking it as stated in the text. The rationale is that shaking the inhaler helps to mix the medication properly before inhalation.
Inhalation Technique
The nurse should instruct the client to exhale fully before bringing the inhaler to their lips and to depress the canister as they inhale the medication. The rationale is that this technique helps to ensure the medication is properly delivered to the lungs.
Cleaning the Inhaler
The nurse should instruct the client to clean the mouthpiece of the inhaler with mild soap and water, not peroxide as stated in the text. The rationale is that peroxide can damage the inhaler components.
Referred Pain
Examples of Referred Pain
The text provides examples of referred pain, such as a client with angina reporting substernal chest pain and a client with pancreatitis reporting left shoulder pain.
