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SAUNDERS COMPREHENSIVE REVIEW FOR THE
NCLEX-RN®
EXAMINATION, SEVENTH EDITION
ISBN: 978-0-323-35851-4
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Library of Congress Cataloging-in-Publication Data
Names: Silvestri, Linda Anne, author.
Title: Saunders comprehensive review for the NCLEX-RN examination / Linda
Anne Silvestri.
Other titles: Comprehensive review for the NCLEX-RN examination
Description: Seventh edition. j St. Louis, Missouri : Elsevier, [2017] j Includes bibliographical references
and index.
Identifiers: LCCN 2016011692 j ISBN 9780323358514 (pbk. : alk. paper)
Subjects: j MESH: Nursing, Practical j Nursing Care j Nursing Process j Examination Questions
Classification: LCC RT62 j NLM WY18.2 j DDC 610.73076–dc23
LC record available at http://lccn.loc.gov/2016011692
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CH AP TER 10
Vital Signs and Laboratory Reference Intervals
PRIORITYCONCEPTS Cellular Regulation; Perfusion
CRITICALTHINK
ING W
hat Should Y
ou Do?
The nurse has just received a client from the postanesthesia
care unit (PACU) and is monitoring the client’s vital signs.
On arrival to the unit, the client’s temperature was 37.2 °C
(98.9 °F) orally, the blood pressure was 142/78 mm Hg,
the heart rate was 98 beats per minute, the respiratory rate
was 14 breaths per minute, and the oxygen saturation was
95% on 3 L of oxygen via nasal cannula. The nurse returns
to the room 30 minutes later to find the client’s temperature
to be 36.8 °C (98.2 °F) orally, the blood pressure 95/54 mm
Hg, the heart rate 118 beats per minute, the respiratory rate
18 breaths per minute, and the oxygen saturation 92% on 3 L
of oxygen via nasal cannula. On the basis of these data, what
actions should the nurse take?
Answer located on p. 119.
I. Vital Signs
A. Description: Vital signs include temperature, pulse,
respirations, blood pressure (BP), oxygen saturation
(pulse oximetry), and pain assessment.
B. Guidelines for measuring vital signs
1. Initial measurement of vital signs provides base-
line data on a client’s health status and is used to
help identify changes in the client’s health status.
2. Some vital sign measurements (temperature,
pulse, respirations, BP, pulse oximetry) may be
delegated to unlicensed assistive personnel
(UAP), but the nurse is responsible for interpret-
ing the findings.
3. The nurse collaborates with the health care pro-
vider (HCP) in determining the frequency of
vital sign assessment and also makes indepen-
dent decisions regarding their frequency on the
basis of the client’s status.
The nurse always documents vital sign measure-
ments and reports abnormal findings to the HCP.
C. When vital signs are measured
1. On initial contact with a client (e.g., when a cli-
ent is admitted to a health care facility)
2. During physical assessment of a client
3. Before and after an invasive diagnostic procedure
or surgical procedure
4. During the administration of medication that
affects the cardiac, respiratory, or temperature-
controlling functions (e.g., in a client who has
a fever); may be required before, during, and
after administration of the medication
5. Before, during, and after a blood transfusion
6. Whenever a client’s condition changes
7. Whenever an intervention (e.g., ambulation)
may affect a client’s condition
8. When a fever or known infection is present
(every 2 to 4 hours)
II. Temperature
A. Description
1. Normal body temperature ranges from 36.4° to
37.5° Celsius (C) (97.5° to 99.5° Fahrenheit
[F]); the average in a healthy young adult is
37.0 °C (98.6 °F).
2. Common measurement sites are the mouth, rec-
tum, axilla, ear, and across the forehead (tempo-
ral artery site); various types of electronic
measuring devices are commonly used.
3. Rectal temperatures are usually 1 °F (0.5 °C)
higher and axillary temperatures about 1 °F
(0.5 °C) lower than the normal oral temperature.
4. Know how to convert a temperature to a Fahren-
heit or Celsius value (Box 10-1).
B. Nursing considerations
1. Time of day
a. Temperature is generally in the low-normal
range at the time of awakening as a result of
muscle inactivity.
b. Afternoon body temperature may be high-
normal as a result of the metabolic process,
activity, and environmental temperature.
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![2. Environmental temperature: Body temperature
is lower in cold weather and higher in warm
weather.
3. Age: Temperature may fluctuate during the first
year of life because the infant’s heat-regulating
mechanism is not fully developed.
4. Physical exercise: Use of the large muscles creates
heat, causing an increase in body temperature.
5. Menstrual cycle: Temperature decreases slightly
just before ovulation but may increase to 1 °F
above normal during ovulation.
6. Pregnancy: Body temperature may consistently
stay at high-normal because of an increase in
the woman’s metabolic rate.
7. Stress: Emotions increase hormonal secretion,
leading to increased heat production and a
higher temperature.
8. Illness: Infective agents and the inflammatory
response may cause an increase in temperature.
9. The inability to obtain a temperature should not
be ignored because it could represent a condition
of hypothermia, a life-threatening condition in
very young and older clients.
C. Methods of measurement
1. Oral
a. If the client has recently consumed hot or cold
foods or liquids or has smoked or chewed
gum, the nurse must wait 15 to 30 minutes
before taking the temperature orally.
b. The thermometer is placed under the tongue in
1 ofthe posterior sublingual pockets;ask the cli-
ent to keep the tongue down and the lips closed
and to not bite down on the thermometer.
2. Rectal
a. Place the client in the Sims position.
b. The temperature is taken rectally when an
accurate temperature cannot be obtained
orally or when the client has nasal conges-
tion, has undergone nasal or oral surgery or
had the jaws wired, has a nasogastric tube
in place, is unable to keep the mouth closed,
or is at risk for seizures.
c. The thermometer is lubricated and inserted
into the rectum, toward the umbilicus, about
1.5 inches (3.8 cm) (no more than 0.5 inch
[1.25 cm] in an infant).
The temperature is not taken rectally in cardiac cli-
ents; the client who has undergone rectal surgery; or the
client with diarrhea, fecalimpaction, or rectal bleeding or
who is at risk for bleeding.
3. Axillary
a. This method of taking the temperature is used
when the oral or rectal temperature measure-
ment is contraindicated.
b. Axillary measurement is not as accurate as the
oral, rectal, tympanic, or temporal artery
method but is used when other methods of
measurement are not possible.
c. The thermometer is placed in the client’s dry
axilla and the client is asked to hold the arm
tightly against the chest, resting the arm on
the chest; follow the instructions accompany-
ing the measurement device for the amount
of time the thermometer should remain in
the axillary area.
4. Tympanic
a. The auditory canal is checked for the presence
of redness, swelling, discharge, or a foreign
body before the probe is inserted; the probe
should not be inserted if the client has an
inflammatory condition of the auditory canal
or if there is discharge from the ear.
b. The reading may be affected by an ear infec-
tion or excessive wax blocking the ear canal.
5. Temporal artery
a. Ensure that the client’s forehead is dry.
b. The thermometer probe is placed flush
against the skin and slid across the forehead
or placed in the area of the temporal artery
and held in place.
c. If the client is diaphoretic, the temporal artery
thermometer probe may be placed on the
neck, just behind the earlobe.
III. Pulse
A. Description
1. The average adult pulse (heart) rate is 60 to 100
beats/min.
2. Changes in pulse rate are used to evaluate the cli-
ent’s tolerance of interventions such as ambula-
tion, bathing, dressing, and exercise.
3. Pedal pulses are checked to determine whether
the circulation is blocked in the artery up to that
pulse point.
4. When the pedal pulse is difficult to locate, a
Doppler ultrasound stethoscope (ultrasonic
stethoscope) may be needed to amplify the
sounds of pulse waves.
B. Nursing considerations
1. The heart rate slows with age.
2. Exercise increases the heart rate.
3. Emotions stimulate the sympathetic nervous sys-
tem, increasing the heart rate.
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BOX 10-1 Body Temperature Conversion
To convert Fahrenheit to Celsius: Degrees Fahrenheit –
32Â 5/9 ¼Degrees Celsius
Example: 98.2 °F – 32Â 5/9 ¼36.7 °C
To convert Celsius to Fahrenheit: Degrees Celsius  9/5
+32¼Degrees Fahrenheit
Example: 38.6 °CÂ 9/5+32¼101.5 °F
109
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![4. For an adult (age 18 and older), a normal BP is a
systolic pressure below 120 mm Hg and a dia-
stolic pressure below 80 mm Hg.
5. Classifications include prehypertension and
stage 1 and stage 2 hypertension (Box 10-3).
6. In postural (orthostatic) hypotension, a normo-
tensive client exhibits symptoms and low BP on
rising to an upright position.
7. To obtain orthostatic vital sign measurements,
check the BP and pulse with the client supine, sit-
ting, and standing; readings are obtained 1 to
3 minutes after the client changes position.
B. Nursing considerations
1. Factors affecting BP
a. BP tends to increase as the aging process
progresses.
b. Stress results in sympathetic stimulation that
increases the BP.
c. The incidence of high BP is higher among
African Americans than among Americans
of European descent.
d. Antihypertensive medications and opioid
analgesics can decrease BP.
e. BP is typically lowest in the early morning,
gradually increases during the day, and peaks
in the late afternoon and evening.
f. After puberty, males tend to have higher BP
than females; after menopause, women tend
to have higher BP than men of the same age.
2. Guidelines for measuring BP
a. Determine the best site for assessment.
b. Avoid applying a cuff to an extremity into
which intravenous (IV) fluids are infusing,
where an arteriovenous shunt or fistula is
present, on the side on which breast or axil-
lary surgery has been performed, or on an
extremity that has been traumatized or is
diseased.
c. The leg may be used if the brachial artery is
inaccessible; the cuff is wrapped around the
thigh and the stethoscope is placed over the
popliteal artery.
d. Ensure that the client has not smoked or exer-
cised in the 30 minutes before measurement
because both activities can yield falsely high
readings.
e. Have the client assume a sitting (with feet flat
on floor) or lying position and then rest for
5 minutes before the measurement; ask the
client not to speak during the measurement.
f. Ensure that the cuff is fully deflated, then
wrap it evenly and snugly around the
extremity.
g. Ensure that the stethoscope being used fits the
examiner and does not impair hearing.
h. Document the first Korotkoff sound at phase
1 (heard as the blood pulsates through the
vessel when air is released from the BP cuff
and pressure on the artery is reduced) as the
systolic pressure and the beginning of the
fifth Korotkoff sound at phase 5 as the dia-
stolic pressure.
i. BP readings obtained electronically with a
vital sign monitoring machine should be
checked with a manual cuff if there is any con-
cern about the accuracy of the reading.
When taking a BP, select the appropriate cuff size;
a cuff that is too small will yield a falsely high reading,
and a cuff that is too large will yield a falsely low one.
VI. Pulse Oximetry
A. Description
1. Pulse oximetry is a noninvasive test that registers
the oxygen saturation of the client’s hemoglobin.
2. The capillary oxygen saturation (SaO2) is
recorded as a percentage.
3. The normal value is 95% to 100%.
4. After a hypoxic client uses up the readily avail-
able oxygen (measured as the arterial oxygen
pressure, PaO2, on arterial blood gas [ABG] test-
ing), the reserve oxygen, that oxygen attached
to the hemoglobin (SaO2), is drawn on to pro-
vide oxygen to the tissues.
5. A pulse oximeter reading can alert the nurse to
hypoxemia before clinical signs occur.
6. If pulse oximetry readings are below normal,
instruct the client in deep breathing technique
and recheck the pulse oximetry.
B. Procedure
1. Asensor is placed on the client’s finger, toe, nose,
earlobe, or forehead to measure oxygen satura-
tion, which then is displayed on a monitor.
2. Maintain the transducer at heart level.
3. Do not select an extremity with an impediment
to blood flow.
Ausual pulse oximetryreading is between 95% and
100%. A pulse oximetry reading lower than 90% neces-
sitates HCP notification; values below 90% are accept-
able only in certain chronic conditions. Agency
procedures and HCP prescriptions are followed regard-
ing actions to take for specific readings.
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BOX 10-3 Hypertension Classifications
Prehypertension: A systolic blood pressure (BP) of 120 to
139 mm Hg or a diastolic pressure of 80 to 89 mm Hg
Stage 1: Asystolic BP of 140 to 159 mm Hg or a diastolic pres-
sure of 90 to 99 mm Hg
Stage 2: Asystolic BP equal to or greater than 160 mm Hg or a
diastolic pressure equal to or greater than 100 mm Hg
111
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![CH AP TER 14
Administration of Blood Products
PRIORITYCONCEPTS Perfusion; Safety
CRITICALTHINK
ING W
hat Should Y
ou Do?
The nurse is administering 1 unit of packed red blood cells
(PRBCs) to a client who has never received a blood transfu-
sion. The client suddenly becomes apprehensive and com-
plains of back pain after the first 10 minutes of
administration. What should the nurse do?
Answer located on p. 163.
I. Types of Blood Components
A. Packed red blood cells (PRBCs)
1. PBRCs are a blood product used to replace eryth-
rocytes; infusion time for 1 unit is usually
between 2 and 4 hours.
2. Each unit increases the hemoglobin level by 1 g/
dL (10 mmol/L) and hematocrit by 3% (0.03);
the change in laboratory values takes 4 to 6 hours
after completion of the blood transfusion.
3. Evaluation of an effective response is based on
the resolution of the symptoms of anemia and
an increase in the erythrocyte, hemoglobin,
and hematocrit count.
4. Leukocyte-poor or leukocyte-depleted units are
unitsin which leukocytes,proteins,andplasmahave
been reduced. They are used to restore oxygen-
carryingcapacityofblood and intravascularvolume.
Washed red blood cells (depleted of plasma, plate-
lets, and leukocytes) maybe prescribed for a client with a
history of allergic transfusion reactions or those who
underwent hematopoietic stem cell transplant. Leuko-
cyte depletion (leukoreduction) by filtration, washing,
or freezing is the process used to decrease the amount
of white blood cells (WBCs) in a unit of packed cells.
B. Platelet transfusion
1. Platelets are used to treat thrombocytopenia and
platelet dysfunctions.
a. Clients receiving multiple units of platelets
can become “alloimmunized” to different
platelet antigens. These clients may benefit
from receiving only platelets that match their
specific human leukocyte antigen (HLA).
2. Crossmatching is not required but usually is done
(platelet concentrates contain few red blood
cells [RBCs]).
3. The volume in a unit of platelets may vary;
always check the bag for the volume of the blood
component (in milliliters).
4. Platelets are administered immediately upon
receipt from the blood bank and are given rap-
idly, usually over 15 to 30 minutes.
5. Evaluation of an effective response is based on
improvement in the platelet count, and platelet
counts normally are evaluated 1 hour and 18
to 24 hours after the transfusion; for each unit
of platelets administered, an increase of 5000
to 10,000 mm3
(5 to 10 Â 109
/L) is expected.
C. Fresh-frozen plasma
1. Fresh-frozen plasma may be used to provide clot-
ting factors or volume expansion; it contains no
platelets.
2. Fresh-frozen plasma is infused within 2 hours
of thawing, while clotting factors are still
viable, and is infused over a period of 15 to
30 minutes.
3. Rh compatibility and ABO compatibility are
required for the transfusion of plasma products.
4. Evaluation of an effective response is assessed
by monitoring coagulation studies, particularly
the prothrombin time and the partial thrombo-
plastin time, and resolution of hypovolemia.
D. Cryoprecipitates
1. Prepared from fresh-frozen plasma, cryoprecipi-
tates can be stored for 1 year. Once thawed, the
product must be used; 1 unit is administered
over 15 to 30 minutes.
2. Used to replace clotting factors, especially factor
VIII and fibrinogen
3. Evaluation of an effective response is assessed by
monitoring coagulation studies and fibrinogen
levels.
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![used in a darkened room]); scars or birthmarks;
edema; capillary filling time (Boxes 15-3 and
15-4; Table 15-1)
3. Dark-skinned client
a. Cyanosis: Check lips and tongue for a gray
color; nail beds, palms, and soles for a blue
color; and conjunctivae for pallor.
b. Jaundice: Check oral mucous membranes for
a yellow color; check the sclera nearest to the
iris for a yellow color.
c. Bleeding: Look for skin swelling and darken-
ing and compare the affected side with the
unaffected side.
d. Inflammation: Check for warmth or a shiny
or taut and pitting skin area, and compare
with the unaffected side.
4. Refer to Chapter 46 for diagnostic tests related to
the integumentary system
To test skin turgor, pinch a large fold of skin and
assess the ability of the skin to return to its place when
released. Poor turgor occurs in severe dehydration or
extreme weight loss.
5. Client teaching
a. Provide information about factors that can be
harmful to the skin, such as sun exposure.
b. Encourage performing self-examination of
the skin monthly.
B. Head, neck, and lymph nodes: Involves inspection
and palpation of the head, neck, and lymph nodes
1. Ask the client about headaches; episodes of diz-
ziness (lightheadedness) or vertigo (spinning
sensation); history of head injury; loss of con-
sciousness; seizures; episodes of neck pain; limi-
tations of range of motion; numbness or tingling
in the shoulders, arms, or hands; lumps or swell-
ing in the neck; difficulty swallowing; medica-
tions being taken; and history of surgery in the
head and neck region.
2. Head
a. Inspect and palpate: Size, shape, masses or
tenderness, and symmetry of the skull
b. Palpate temporal arteries, located above the
cheekbone between the eye and the top of
the ear.
c. Temporomandibular joint: Ask the client to
open his or her mouth; note any crepitation,
tenderness, or limited range of motion.
d. Face: Inspect facial structures for shape, sym-
metry, involuntary movements, or swelling,
such as periorbital edema (swelling around
the eyes).
3. Neck
a. Inspect for symmetry of accessory neck
muscles.
b. Assess range of motion.
c. Test cranial nerve XI (spinal accessory nerve)
to assess muscle strength: Ask the client to
push against resistance applied to the side
of the chin (tests sternocleidomastoid mus-
cle); also ask the client to shrug the shoulders
against resistance (tests trapezius muscle).
d. Palpate the trachea: It should be midline,
without any deviations.
e. Thyroid gland: Inspect the neck as the
client takes a sip of water and swallows
(thyroid tissue moves up with a swallow);
palpate using an anterior-posterior approach
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TABLE 15-1 Pitting Edema Scale
Scale Description “Measurement”*
1+ A barely perceptible pit 2 mm (3
=32 in)
2+
4
mm
1+
2
mm
3+
6
mm
4+
8
mm
2+ A deeper pit, rebounds in a few
seconds
4 mm (6
32 in)
3+ A deep pit, rebounds in 10-20 sec 6 mm (1
=4 in)
4+ A deeper pit, rebounds in > 30 sec 8 mm (5
=16 in)
*“Measurement” is in quotation marks because depth of edema is rarely actually measured but is included as a frame of reference.
Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 2013, Mosby. Description column data from Kirton C: Assessing edema, Nursing 96
26(7):54, 1996.
BOX 15-4 Assessing Capillary Filling Time
1. Depress the nail bed to produce blanching.
2. Release and observe for the return of color.
3. Color will return within 3 seconds if arterial capillary perfu-
sion is normal.
BOX 15-3 Characteristics of Skin Color
Cyanosis: Mottled bluish coloration
Erythema: Redness
Pallor: Pale, whitish coloration
Jaundice: Yellow coloration
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![(usually the normal adult thyroid cannot be
palpated); if it is enlarged, auscultate for
a bruit.
4. Lymph nodes
a. Palpate using a gentle pressure and a circular
motion of the finger pads.
b. Begin with the preauricular lymph nodes (in
front of the ear); move to the posterior auric-
ular lymph nodes and then downward
toward the supraclavicular lymph nodes.
c. Palpate with both hands, comparing the 2
sides for symmetry.
d. If nodes are palpated, note their size, shape,
location, mobility, consistency, and
tenderness.
5. Client teaching: Instruct the client to notify the
health care provider (HCP) if persistent head-
ache, dizziness, or neck pain occurs; if swelling
or lumps are noted in the head and neck region;
or if a neck or head injury occurs.
Neck movements are never performed if the client
has sustained a neck injury or if a neck injury is
suspected.
C. Eyes: Includes inspection, palpation, vision-testing
procedures, and the use of an ophthalmoscope
1. Subjective data: Difficulty with vision (e.g.,
decreased acuity, double vision, blurring, blind
spots); pain, redness, swelling, watery or other
discharge from the eye; use of glasses or contact
lenses; medications being taken; history of eye
problems
2. Objective data
a. Inspect the external eye structures, including
eyebrows, for symmetry; eyelashes for even
distribution; eyelids for ptosis (drooping);
eyeballs for exophthalmos (protrusion) or
enophthalmos (recession into the orbit;
sunken eye).
b. Inspect the conjunctiva (should be clear),
sclera (should be white), and lacrimal appara-
tus (check for excessive tearing, redness, ten-
derness, or swelling); cornea and lens
(should be smooth and clear); iris (should
be flat, with a round regular shape and even
coloration); eyelids; and pupils
3. Snellen eye chart
a. The Snellen eye chart is a simple tool used to
measure distance vision.
b. Position the client in a well-lit spot 20 feet (6
meters) from the chart, with the chart at eye
level, and ask the client to read the smallest
line that he or she can discern.
c. Instruct the client to leave on glasses or leave
in contact lenses; if the glasses are for reading
only, they are removed because they blur dis-
tance vision.
d. Test 1 eye at a time.
e. Record the result using the fraction at the end
of the last line successfully read on the chart.
f. Normal visual acuity is 20/20 (distance in feet
at which the client is standing from the chart/
distance in feet at which a normal eye could
have read that particular line).
4. Near vision
a. Use a hand-held vision screener (held about
14 inches [35.5 centimeters] from the eye)
that contains various sizes of print or ask
the client to read from a magazine.
b. Test each eye separately with the client’s
glasses on or contact lenses in.
c. Normal result is 14/14 (distance in inches at
which the subject holds the card from the
eye/distance in inches at which a normal eye
could have read that particular line).
5. Confrontation test
a. Acrude but rapid test used to measure periph-
eral vision and compare the client’s periph-
eral vision with the nurse’s (assuming that
the nurse’s peripheral vision is normal)
b. The client covers 1 eye and looks straight
ahead; the nurse, positioned 2 feet away (60
centimeters), covers his or her eye opposite
the client’s covered eye.
c. The nurse advances a finger or other small
object from the periphery from several direc-
tions; the client should see the object at the
same time the nurse does.
6. Corneal light reflex
a. Used to assess for parallel alignment of the
axes of the eyes
b. Client is asked to gaze straight ahead as the
nurse holds a light about 12 inches (30 centi-
meters) from the client.
c. The nurse looks for reflection ofthe light on the
corneas in exactly the same spot in each eye.
7. Cover test
a. Used to check for slight degrees of deviated
alignment
b. Each eye is tested separately.
c. The nurse asks the client to gaze straight
ahead and cover 1 eye.
d. The nurse examines the uncovered eye,
expecting to note a steady, fixed gaze.
8. Extraocular muscle function (6 cardinal posi-
tions of gaze) (Fig. 15-1)
a. The 6 muscles that attach the eyeball to its
orbit and serve to direct the eye to points of
interest are tested.
b. Client holds head still and is asked to move
his or her eyes and follow a small object.
c. The examiner notes any parallel movements
of the eye or nystagmus, an involuntary,
rhythmic, rapid twitching of the eyeballs.
F
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s
174 UNIT IV Fundamentals of Care](https://image.slidesharecdn.com/saunderscomprehensivereviewforthenclex-rnexamination-250806110839-e9f53e98/85/Saundersa-Comprehensive-Review-for-the-NCLEX-RN-Examination-pdf-192-320.jpg)
![C. Smallpox (Fig. 16-2)
1. Smallpox is transmitted in air droplets and by
handling contaminated materials and is highly
contagious.
2. Symptoms begin 7 to 17 days after exposure and
include fever, back pain, vomiting, malaise, and
headache.
3. Papules develop 2 days after symptoms develop
and progress to pustular vesicles that are abun-
dant on the face and extremities initially.
4. Avaccine is available to those at risk for exposure
to smallpox.
D. Botulism
1. Botulism is a serious paralytic illness caused by a
nerve toxin produced by the bacterium Clostrid-
ium botulinum (death can occur within 24 hours).
2. Its spores are found in the soil and can spread
through the air or food (improperly canned
food) or via a contaminated wound.
3. Botulism cannot be spread from person to person.
4. Symptoms include abdominal cramps, diarrhea,
nausea and vomiting, double vision, blurred
vision, drooping eyelids, difficulty swallowing
or speaking, dry mouth, and muscle weakness.
5. Neurological symptoms begin 12 to 36 hours
after ingestion of food-borne botulism and 24
to 72 hours after inhalation and can progress
to paralysis of the arms, legs, trunk, or respiratory
muscles (mechanical ventilation is necessary).
6. If diagnosed early, food-borne and wound botu-
lism can be treated with an antitoxin that blocks
the action of toxin circulating in the blood.
7. Other treatments include induction of vomiting,
enemas, and penicillin.
8. No vaccine is available.
E. Plague
1. Plague is caused by Yersinia pestis, a bacteria
found in rodents and fleas.
2. Plague is contracted by being bitten by a rodent
or flea that is carrying the plague bacterium, by
the ingestion of contaminated meat, or by han-
dling an animal infected with the bacteria.
3. Transmission isbydirect person-to-person spread.
4. Forms include bubonic (most common), pneu-
monic, and septicemic (most deadly).
5. Symptoms usually begin within 1 to 3 days and
include fever, chest pain, lymph node swelling,
and a productive cough (hemoptysis).
6. The disease rapidly progresses to dyspnea, stri-
dor, and cyanosis; death occurs from respiratory
failure, shock, and bleeding.
7. Antibiotics are effective only if administered
immediately; the usual medications of choice
include streptomycin or gentamicin.
8. A vaccine is available.
F. Tularemia
1. Tularemia (also called deer flyfever or rabbit fever)
is an infectious disease of animals caused by the
bacillus Francisella tularensis.
2. The disease is transmitted by ticks, deer flies, or
contact with an infected animal.
3. Symptoms include fever, headache, and an ulcer-
ated skin lesion with localized lymph node
enlargement, eye infections, gastrointestinal
ulcerations, or pneumonia.
4. Treatment is with antibiotics.
5. Recovery produces lifelong immunity (a vaccine
is available).
G. Hemorrhagic fever
1. Hemorrhagic fever is caused by several viruses,
including Marburg, Lassa, Junin, and Ebola.
2. The virus is carried by rodents and mosquitoes.
3. The disease can be transmitted directly by
person-to-person spread via body fluids.
4. Symptoms include fever, headache, malaise, con-
junctivitis, nausea, vomiting, hypotension, hem-
orrhage of tissues and organs, and organ failure.
5. No known specific treatment is available; treat-
ment is symptomatic.
H. Ebola Virus Disease (EVD)
1. Previously known as Ebola hemorrhagic fever
2. Caused by infection with a virus of the family
Filoviridae, genus Ebolavirus
3. First discovered in 1976 in theDemocraticRepublic
of the Congo. Outbreaks have appeared in Africa.
4. The natural reservoir host of Ebolavirus remains
unknown. It is believed that the virus is animal-
borne and that bats are the most likely reservoir.
5. Spread of the virus is through contact with
objects (such as clothes, bedding, needles, syrin-
ges/sharps, or medical equipment) that have
been contaminated with the virus.
6. Symptoms similar to hemorrhagic fever may
appear from 2 to 21 days after exposure.
7. Assessment: Ask the client if he or she traveled to
an area with EVD such as Guinea, Liberia, or
Sierra Leone within the last 21 days or if he or
she has had contact with someone with EVD
and had any of the following symptoms:
F
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e
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FIGURE 16-2 Smallpox. (Courtesy Centers for Disease Control and Pre-
vention [CDC]: Evaluating patients for smallpox. Atlanta, 2002, CDC.)
198 UNIT IV Fundamentals of Care](https://image.slidesharecdn.com/saunderscomprehensivereviewforthenclex-rnexamination-250806110839-e9f53e98/85/Saundersa-Comprehensive-Review-for-the-NCLEX-RN-Examination-pdf-216-320.jpg)
Saundersa Comprehensive Review for the NCLEX-RN Examination.pdf
- 2. Evolve Student Resources for Silvestri: Saunders Comprehensive Review for the NCLEX-RN® Examination, Seventh Edition, include the following: How to Use the Online Practice Questions: Customize your study session for your time and your own unique needs. • Pre-test of 75 questions evaluates your current knowledge. These results feed into a personalized Study Calendar to help guide you in your preparation for the NCLEX-RN examination. • Study Mode: Receive immediate feedback after each question. Select questions by Client Needs, Integrated Process, Alternate Item Format Type, Priority Concept, or specific Content Area. The answer, rationale, test-taking strategy, question codes, priority concepts, and reference sources for further remediation appear immediately after you answer each question. • Exam Mode: Take a practice exam, and receive your results and feedback at the end. Select questions by Client Needs, Integrated Process, Alternate Item Format Type, Priority Concept, or specific Content Area. Then select the number of questions you'd like to take in your exam—10, 25, 50, or 100. When you've finished the exam, the percentage of questions you answered correctly will be shown in a table, and you can go back to review the correct answers—as well as rationales, test-taking strategies, question codes, priority concepts, and reference(s)—for each question. • Post-test of 75 questions simulating the NCLEXClient Needs percentages helps you evaluate your progress. Activate the complete learning experience that comes with each NEW textbook purchase by registering with your scratch-off access code at http://evolve.elsevier.com/Silvestri/comprehensiveRN/ If you purchased a used book and the scratch-off code at right has already been revealed, the code may have been used and cannot be re-used for registration. To purchase a new code to access these valuable study resources, simply follow the link above. *Evolve Student Resources are provided free with each NEW book purchase only.
- 3. Instructor of Nursing Salve Regina University, Newport, Rhode Island President Nursing Reviews, Inc., Henderson, Nevada Nursing Reviews, Inc., Charlestown, Rhode Island and Professional Nursing Seminars, Inc., Charlestown, Rhode Island Elsevier Consultant HESI NCLEX-RN® and NCLEX-PN® Live Review Courses Assistant Professor Touro University Nevada—School of Nursing Henderson, Nevada
- 4. 3251 Riverport Lane St. Louis, Missouri 63043 SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION, SEVENTH EDITION ISBN: 978-0-323-35851-4 Copyright © 2017 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practices in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2014, 2012, and 2009. NCLEX® , NCLEX-RN® , and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc. Library of Congress Cataloging-in-Publication Data Names: Silvestri, Linda Anne, author. Title: Saunders comprehensive review for the NCLEX-RN examination / Linda Anne Silvestri. Other titles: Comprehensive review for the NCLEX-RN examination Description: Seventh edition. j St. Louis, Missouri : Elsevier, [2017] j Includes bibliographical references and index. Identifiers: LCCN 2016011692 j ISBN 9780323358514 (pbk. : alk. paper) Subjects: j MESH: Nursing, Practical j Nursing Care j Nursing Process j Examination Questions Classification: LCC RT62 j NLM WY18.2 j DDC 610.73076–dc23 LC record available at http://lccn.loc.gov/2016011692 Content Strategist: Jamie Blum Content Development Manager: Laurie Gower Content Development Specialist: Laura Goodrich Publishing Services Manager: Jeff Patterson Book Production Specialist: Bill Drone Designer: Renee Duenow Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1
- 5. Contents UNIT I NCLEX-RN® Exam Preparation, 1 1 The NCLEX-RN® Examination, 2 2 Pathways to Success, 14 3 The NCLEX-RN® Examination from a Graduate’s Perspective, 18 4 Test-Taking Strategies, 20 UNIT II Professional Standards in Nursing, 30 5 Cultural Awareness and Health Practices, 32 6 Ethical and Legal Issues, 44 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning, 59 UNIT III Nursing Sciences, 76 8 Fluids and Electrolytes, 78 9 Acid-Base Balance, 97 10 Vital Signs and Laboratory Reference Intervals, 108 11 Nutrition, 124 12 Parenteral Nutrition, 134 13 Intravenous Therapy, 144 14 Administration of Blood Products, 158 UNIT IV Fundamentals of Care, 169 15 Health and Physical Assessment of the Adult Client, 171 16 Provision of a Safe Environment, 192 17 Calculation of Medication and Intravenous Prescriptions, 204 18 Perioperative Nursing Care, 215 19 Positioning Clients, 230 20 Care of a Client with a Tube, 239 UNIT V Growth and Development Across the Life Span, 255 21 Theories of Growth and Development, 257 22 Developmental Stages, 265 23 Care of the Older Client, 281 UNIT VI Maternity Nursing, 289 24 Reproductive System, 291 25 Prenatal Period, 299 26 Risk Conditions Related to Pregnancy, 314 27 Labor and Birth, 332 28 Problems with Labor and Birth, 346 29 Postpartum Period, 356 30 Postpartum Complications, 364 31 Care of the Newborn, 372 32 Maternity and Newborn Medications, 393 UNIT VII Pediatric Nursing, 403 33 Integumentary Disorders, 404 34 Hematological Disorders, 411 35 Oncological Disorders, 419 36 Metabolic and Endocrine Disorders, 430 37 Gastrointestinal Disorders, 439 38 Eye, Ear, and Throat Disorders, 457 39 Respiratory Disorders, 463 40 Cardiovascular Disorders, 479 41 Renal and Urinary Disorders, 491 42 Neurological and Cognitive Disorders, 499 43 Musculoskeletal Disorders, 511 44 Infectious and Communicable Diseases, 520 45 Pediatric Medication Administration and Calculations, 536 iii
- 6. UNIT VIII Integumentary Disorders of the Adult Client, 543 46 Integumentary System, 544 47 Integumentary Medications, 569 UNIT IX Hematological and Oncological Disorders of the Adult Client, 578 48 Hematological and Oncological Disorders, 580 49 Hematological and Oncological Medications, 614 UNIT X Endocrine Disorders of the Adult Client, 625 50 Endocrine System, 626 51 Endocrine Medications, 653 UNIT XI Gastrointestinal Disorders of the Adult Client, 669 52 Gastrointestinal System, 671 53 Gastrointestinal Medications, 698 UNIT XII Respiratory Disorders of the Adult Client, 706 54 Respiratory System, 708 55 Respiratory Medications, 737 UNIT XIII Cardiovascular Disorders of the Adult Client, 754 56 Cardiovascular System, 755 57 Cardiovascular Medications, 797 UNIT XIV Renal and Urinary Disorders of the Adult Client, 815 58 Renal and Urinary System, 817 59 Renal and Urinary Medications, 850 UNIT XV Eye and Ear Disorders of the Adult Client, 860 60 The Eye and the Ear, 861 61 Eye and Ear Medications, 882 UNIT XVI Neurological Disorders of the Adult Client, 892 62 Neurological System, 893 63 Neurological Medications, 923 UNIT XVII Musculoskeletal Disorders of the Adult Client, 936 64 Musculoskeletal System, 937 65 Musculoskeletal Medications, 958 UNIT XVIII Immune Disorders of the Adult Client, 965 66 Immune Disorders, 966 67 Immunological Medications, 980 UNIT XIX Mental Health Disorders of the Adult Client, 987 68 Foundations of Psychiatric Mental Health Nursing, 988 69 Mental Health Disorders, 1000 70 Addictions, 1019 71 Crisis Theory and Intervention, 1030 72 Psychiatric Medications, 1043 UNIT XX Comprehensive Test, 1056 References, 1079 Glossary, 1081 Index, 1090 Priority Nursing Action List, Back of Inside Cover iv Contents
- 7. To my parents— To my mother, Frances Mary, and in loving memory of my father, Arnold Lawrence, who taught me to always love, care, and be the best that I could be.
- 8. To All Future Registered Nurses, Congratulations to you! You should be very proud and pleased with yourself on your most recent well- deserved accomplishment of completing your nursing program to become a regis- tered nurse. I know that you have worked very hard to become successful and that you have proven to yourself that indeed you can achieve your goals. In my opinion, you are about to enter the most wonderful and rewarding profession that exists. Your willingness, desire, and ability to assist those who need nursing care will bring great satisfaction to your life. In the profession of nursing, your learning will be a lifelong process. This aspect of the profession makes it stim- ulating and dynamic. Your learning process will continue to expand and grow as the profession continues to evolve. Your next very important endeavor will be the learning process involved to achieve success in your examination to become a registered nurse. I am excited and pleased to be able to provide you with the Saunders Pyramid to Success products, which will help you prepare for your next important professional goal, becoming a registered nurse. I want to thank all of my former nursing students whom I have assisted in their studies for the NCLEX-RN® examination for their willingness to offer ideas regarding their needs in preparing for licensure. Student ideas have certainly added a special uniqueness to all of the products available in the Saunders Pyramid to Success. Saunders Pyramid to Success products provide you with everything that you need to ready yourself for the NCLEX-RN examination. These products include material that is required for the NCLEX-RN examination for all nursing students regardless of educational background, specific strengths, areas in need of improvement, or clinical experience during the nursing program. So let’s get started and begin our journey through the Saunders Pyramid to Success, and welcome to the wonderful profession of nursing! Sincerely, vi
- 9. About the Author Linda Anne Silvestri, PhD, RN (Photo by Laurent W. Valliere.) As a child, I always dreamed of becoming either a nurse or a teacher. Initially I chose to become a nurse because I really wanted to help others, espe- cially those who were ill. Then I realized that both of my dreams could come true; I could be both a nurse and a teacher. So I pursued my dreams. I received my diploma in nursing at Cooley Dickin- son Hospital School of Nursing in Northampton, Mas- sachusetts. Afterward, I worked at Baystate Medical Center in Springfield, Massachusetts, where I cared for clients in acute medical-surgical units, the intensive care unit, the emergency department, pediatric units, and other acute care units. Later I received an associate degree from Holyoke Community College in Holyoke, Massa- chusetts; my BSN from American International College in Springfield, Massachusetts; and my MSN from Anna Maria College in Paxton, Massachusetts, with a dual major in Nursing Management and Patient Education. I received my PhD in Nursing from the University of Nevada, Las Vegas, and conducted research on self- efficacy and the predictors of NCLEX® success. I am also a member of the Honor Society of Nursing, Sigma Theta Tau International, Phi Kappa Phi, the American Nurses Association, the National League for Nursing, the West- ern Institute of Nursing, the Eastern Nursing Research Society, and the Golden Key International Honour Soci- ety. In addition, I received the 2012 Alumna of the Year/ Nurse of the Year Award from the University of Nevada, Las Vegas, School of Nursing. As a native of Springfield, Massachusetts, I began my teaching career as an instructor of medical-surgical nurs- ing and leadership-management nursing in 1981 at Baystate Medical Center School of Nursing. In 1989, I relocated to Rhode Island and began teaching ad- vanced medical-surgical nursing and psychiatric nursing to RN and LPN students at the Community College of Rhode Island. While teaching there, a group of students approached me for assistance in preparing for the NCLEX examination. I have always had a very special interest in test success for nursing students because of my own personal experiences with testing. Taking tests was never easy for me, and as a student I needed to find methods and strategies that would bring success. My own difficult experiences, desire, and dedication to assist nursing students to overcome the obstacles associated with testing inspired me to develop and write the many products that would foster success with testing. My expe- riences as a student, nursing educator, and item writer for the NCLEX examinations aided me as I developed a comprehensive review course to prepare nursing graduates for the NCLEX examination. Later, in 1994, I began teaching medical-surgical nursing at Salve Regina University in Newport, Rhode Island, and I remain there as an adjunct faculty member. I also prepare nursing students at Salve Regina University for the NCLEX-RN examination. I established Professional Nursing Seminars, Inc. in 1991 and NursingReviews, Inc. in 2000. These companies are located in Charlestown, Rhode Island. In 2012, I estab- lished an additional company, Nursing Reviews, Inc. in Henderson, Nevada. Both companies are dedicated to helpingnursinggraduates achieve their goals ofbecoming registered nurses, licensed practical/vocational nurses, or both. Today, I am the successful author of numerous review products. Also, I serve as an Elsevier consultant for HESI Live Reviews, the review courses for the NCLEX examinations conducted throughout the country. I am so pleased that you have decided to join me on your journey to success in testing for nursing examinations and for the NCLEX-RN examination! vii
- 10. Contributors Consultants Dianne E. Fiorentino Research Coordinator Nursing Reviews, Inc. Henderson, Nevada James Guibault, Jr., BS, PharmD Clinical Pharmacist Wilbraham, Massachusetts Nicholas L. Silvestri, BA Editorial and Communications Analyst Nursing Reviews, Inc. Charlestown, Rhode Island Jane Tyerman, RN, MScN, PhD Faculty Trent/Fleming School of Nursing Peterborough, Ontario, Canada Contributors Marilee Aufdenkamp, BSN, MS Assistant Professor School of Nursing Creighton University Omaha, Nebraska Jaskaranjeet Bhullar, RN Graduate School of Nursing Touro University Nevada Henderson, Nevada Jean Burt, BS, BSN, MSN Instructor, Nursing City Colleges of Chicago Chicago, Illinois Reitha Cabaniss, EdD, MSN Nursing Director Bevill State Community College Jasper, Alabama Barbara Callahan, MEd, RN, NCC, CHSE Retired Lenoir Community College Kinston, North Carolina Nancy Curry, BSN, MSN Assistant Professor, Nursing Northwestern State University College of Nursing and School of Allied Health Shreveport, Louisiana Mattie Davis, DNP, MSN, RN Nursing Instructor, Health Sciences J.F. Drake State Technical College Huntsville, Alabama Margie Francisco, EdD, MSN, RN Nursing Professor Health Division Illinois Valley Community College Oglesby, Illinois Marilyn Greer, MS, RN Associate Professor of Nursing Rockford College Rockford, Illinois Joyce Hammer, RN, MSN Adjunct Faculty, Nursing Monroe County Community College Monroe, Michigan Donna Russo, MSN, CCRN, CNE Nursing Instructor ARIA Health School of Nursing Philadelphia, Pennsylvania Mary Scheid, RN, MSN NCMC Breast Center North Colorado Medical Center Greeley, Colorado Laurent W. Valliere, BS, DD Vice President of Nursing Reviews, Inc. Professional Nursing Seminars, Inc. Charlestown, Rhode Island Donna Wilsker, MSN, BSN Assistant Professor Dishman Department of Nursing Lamar University Beaumont, Texas viii
- 11. Item W riter and Section Editor Donna Russo, MSN, CCRN, CNE Nursing Instructor ARIA Health School of Nursing Philadelphia, Pennsylvania Item W riters Amber Ballard, MSN, RN Registered Nurse Emergency Department Sparrow Health System Lansing, Michigan Betty Cheng, MSN Assistant Professor School of Nursing MCPHS University Boston, Massachusetts Christina Keller, MSN, RN Instructor School of Nursing Radford University Radford, Virginia Heidi Monroe, MSN, RN-BC, CAPA Assistant Professor of Nursing NCLEX-RN® Coordinator Bellin College Green Bay, Wisconsin Bethany Hawes Sykes, EdD, RN, CEN, CCRN Emergency Department RN St Luke’s Hospital New Bedford, Massachusetts Adjunct Faculty Department of Nursing Salve Regina University Newport, Rhode Island Linda Turchin, RN, MSN, CNE Assistant Professor, Nursing Fairmont State University Fairmont, West Virginia Donna Wilsker, MSN, BSN Assistant Professor Dishman Department of Nursing Lamar University Beaumont, Texas Olga Van Dyke, PhD (c), CAGS, MSN Assistant Professor School of Nursing MCPHS University Boston, Massachusetts The author and publisher would also like to acknowledge the following individuals for contributions to the previous edition of this book: Marilee Aufdenkamp, RN, MS Hastings, Nebraska Margaret Barnes, MSN, RN Marion, Indiana Reitha Cabaniss, MSN, RN, CNE Jasper, Alabama Joanna E. Cain, BSN, BA, RN Austin, Texas Barbara Callahan, MEd, RN, NCC, CHSE Kinston, North Carolina Mary C. Carrico, MS, RN Paducah, Kentucky Mary L. Dowell, PhD, RN, BC San Antonio, Texas Beth B. Gaul, PhD, RN Des Moines, Iowa Susan Golden, MSN, RN Roswell, New Mexico Marilyn L. Johnessee Greer, MS, RN Rockford, Illinois Jamie Lynn Jones, MSN, RN, CNE Little Rock, Arkansas Lynn Korvick, PhD, RN, CNE Joplin, Missouri Tara McMillan-Queen, RN, MSN, ANP, GNP Charlotte, North Carolina Heidi Monroe, MSN, RN-BC, CPAN, CAPA Green Bay, Wisconsin David Morrow, BSN, RN Las Vegas, Nevada Debra L. Price, RN, MSN, CPNP Fort Worth, Texas Donna Russo, RN, MSN, CCRN Philadelphia, Pennsylvania Angela Silvestri, PhD, RN, CNE Henderson, Nevada Christine Sump, MSN, RN Norfolk, Virginia Bethany Hawes Sykes, EdD, RN, CEN, CCRN Newport, Rhode Island Linda Turchin, RN, MSN, CNE Fairmont, West Virginia Laurent W. Valliere, BS, DD Charlestown, Rhode Island ix Contributors
- 12. Reviewers Danese M. Boob, RN-BC, BSN, MSN/ED Certification in Perinatal Nursing and Medical-Surgical Nursing Department of Nursing Pennsylvania State University Hershey, Pennsylvania Jean Elizabeth Burt, MS, RN Nursing Instructor Wilbur Wright College Chicago, Illinois Betty Cheng, MSN, RN, FNP Instructor of Nursing School of Nursing Quincy College Quincy, Massachusetts Marguerite C. DeBello, RN, MSN, ACNS-BC, CNE, NP Assistant Professor School of Nursing Eastern Michigan University Ypsilanti, Michigan Margie L. Francisco, EdD, MSN, RN Nursing Professor Nursing/Health Professions Department Illinois Valley Community College Oglesby, Illinois Shari Gould, MSN, RN Associate Professor of Nursing Career, Health and Technical Professions Department Victoria College Victoria, Texas Sheila Grossman, PhD, APRN, FNP-BC, FAAN Professor & Coordinator, Family Nurse Practitioner Track Nursing Department Fairfield University School of Nursing Fairfield, Connecticut Joyce Hammer, RN, MSN Adjunct Clinical Faculty Nursing Department Monroe County Community College Monroe, Michigan Lilah M. Harper, RN, CA President, Harper Consulting Services Valley Center, California Lead Nurse Planner, Anderson Continuing Education Sacramento, California Laura Hope, MSN, RN Nursing Faculty Nursing Program Florence-Darlington Technical College Florence, South Carolina Donna Walker Hubbard, RN, MSN, CNNe Assistant Professor, Retired Nursing Department University of Mary Hardin-Baylor Belton, Texas Paula Celeste Hughes, MSN, RN Nursing Faculty Nursing and Allied Health Department Georgia Northwestern Technical College Rome, Georgia Georgina Julious, RN, BSN, MSN BLS Instructor; Facility Administrator Nursing Department Out-Patient Dialysis Hartsville, South Carolina Elizabeth B. McGrath, MS, APRN, AGACNP-BC, AOCNP, ACHPN Nurse Practitioner Dartmouth Hitchcock Medical Center—Geisel School of Medicine at Dartmouth Lebanon, New Hampshire Pat A. Perryman, MSN, RN, PhD President Administration Dallas Nursing Institute Dallas, Texas Karen Robertson, RN, MSN, MBA, PhD(c) Associate Professor Nursing Department Rock Valley College Rockford, Illinois x
- 13. Charlotte D. Strahm, DNSc, RN, CNS Assistant Professor Department of Nursing Purdue University North Central Westville, Indiana Christine Sump, MSN, RN Nursing Lecturer Nursing Department Old Dominion University Norfolk, Virginia Daryle Wane, PhD, ARNP, FNP-BC RN to BSN Coordinator Department of Health Occupations Pasco-Hernando State College New Port Richey, Florida Donna Wilsker, MSN, RN Assistant Professor Dishman Department of Nursing Lamar University Beaumont, Texas Karen Winsor, MSN, RN, ACNS-BC APRN for Orthopedic Trauma Austin, Texas xi Reviewers
- 14. Preface “To laugh often and much, to appreciate beauty, to find the best in others, to leave the world a bit better, to know that even one life has breathed easier because you have lived, this is to have succeeded.” —Ralph Waldo Emerson Welcome to Saunders Pyramid to Success! A n Essential Resource for Test Success SaundersComprehensive Reviewfor the NCLEX-RN® Exam- ination is one in a series of products designed to assist you in achieving your goal of becoming a registered nurse. This text will provide you with a comprehensive review of all nursing content areas specifically related to the new 2016 test plan for the NCLEX-RN examina- tion, which is implemented by the National Council of State Boards of Nursing. This resource will help you achieve success on your nursing examinations dur- ing nursing school and on the NCLEX-RN examination. Organization This book contains 20 units and 72 chapters. The chap- ters are designed to identify specific components of nurs- ing content. They contain practice questions, including a critical thinking question, and both multiple-choice and alternate item formats that reflect the chapter content and the 2016 test plan for the NCLEX-RN examination. The final unit contains a 75-question Comprehensive Test. All questions in the book and on the Evolve site are presented in NCLEX-style format. The new test plan identifies a framework based on Client Needs. These Client Needs categories include Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Integrated Processes are also identified as a com- ponent of the test plan. These include Caring, Communi- cation and Documentation, Culture and Spirituality, Nursing Process, and Teaching and Learning. All chapters address the components of the test plan framework. Special Features of the Book Pyramid Terms Pyramid Termsare important to the discussion of the con- tent in the chapters in each unit. Therefore, they are in bold green type throughout the content section of each chapter. The definitions can be found in the Glossary at the end of the book. Pyramid to Success The Pyramid to Success, a featured part of each unit in- troduction, provides you with an overview, guidance, and direction regardingthefocusofreviewin theparticular content area, as well as the content area’s relative impor- tance to the 2016 test plan for the NCLEX-RN examina- tion. The Pyramid to Success reviews the Client Needs and provides learning objectives as they pertain to the content in that unit. These learning objectives identify the specific components to keep in mind as you review each chapter. Priority Concepts Each chapter identifies two Priority Concepts reflective of its content. These PriorityConceptswill assist you to focus on the important aspects of the content and associated nursing interventions. Pyramid Points Pyramid Points ( ) are placed next to specific content throughout the chapters. The Pyramid Pointshighlight con- tent that is important for preparing for the NCLEX-RN examination and identify content that is likely to appear on the NCLEX-RN examination. Pyramid A lerts Pyramid Alerts are the red text found throughout the chapters that alert you to important information about nursing concepts. These alerts identify content that typically appears on the NCLEX-RN examination. Priority Nursing A ctions Numerous PriorityNursing Actions boxes have been placed throughout the chapters. These boxes present a clinical nursing situation and the priority actions to take in the event ofitsoccurrence. Arationale isprovided that explains the correct order of action, along with a reference for addi- tional research. A list of these boxes can be found in the backmatter of the book for easier location. xii
- 15. Critical Thinking: W hat Should Y ou Do? Questions Each chapter contains a Critical Thinking: What Should You Do? question. These questions provide a brief clinical sce- nario related to the content of the chapter and ask you what you should do about the client situation presented. A narrative answer is provided along with a reference source for researching further information. Special Features Found on Evolve Pretest and Study Calendar The accompanying Evolve site contains a 75-question pre- test that providesyou with feedback on your strengths and weaknesses. The results of your pretest will generate an individualized study calendar to guide you in your prepa- ration for the NCLEX-RN examination. Heart, Lung, and Bowel Sound Questions The accompanying Evolve site contains AudioQuestions representative of content addressed in the 2016 test plan for the NCLEX-RN examination. Each question presents an audio clip as a component of the question. V ideo Questions The accompanying Evolve site contains Video Questions representative of content addressed in the 2016 test plan for the NCLEX-RN examination. Each question presents a video clip as a component of the question. Testlet Questions The accompanying Evolve site contains testlet questions. These question types include a client scenario and sev- eral accompanying practice questions that relate to the content of the scenario. A udio ReviewSummaries and A nimations The companion Evolve site includes three Audio Review Summariesthat cover challenging subject areas addressed in the 2016 test plan for the NCLEX-RN examination, including Pharmacology, Acid-Base Balance, and Fluids and Electrolytes. Animations that present various content areas are also available for viewing. Practice Questions While preparing for the NCLEX-RN examination, it is crucial for students to practice taking test questions. This book contains 996 NCLEX-style multiple-choice and alternate item format questions. The accompanying soft- ware includes all questions from the book plus additional Evolve questions for a total of more than 5200 questions. Multiple-Choice and A lternate Item Format Questions Starting with Unit II, each chapter is followed by a prac- tice test. Each practice test contains several questions reflective of those presented on the NCLEX-RN examina- tion. These questions provide you with practice in prioritizing, decision-making, and critical thinking skills. Chapter 1 of this book provides a description of each question type and the answer section. The answer section includes the correct answer, rationale, test-taking strategy, question categories, and reference. In each practice question, the specific test-taking strat- egy that will assist you in answering the question correctly is highlighted in bold blue type. Specific suggestions for review are identified in the test-taking strategy and are highlighted in bold magenta type to provide you with direction for locatingthe specificcontent in thisbook. This highlighting of the specific test-taking strategies and spe- cific content areas in the practice questions will provide you with guidance on what topics to review for further remediation in both Saunders Strategies for Test Success: PassingNursingSchool and theNCLEX® Exam and Saunders Comprehensive Review for the NCLEX-RN® Examination. The categories identified in each practice question include Level of Cognitive Ability, Client Needs, Integrat- ed Process, Priority Concepts, and the specific nursing Content Area.Everyquestion on theaccompanyingEvolve site is organized by these question codes, so you can cus- tomize your study session to be as specific or as generic as you need. Additionally, normal laboratory reference intervals are provided with each laboratory question. Pharmacology and Medication Calculations Review Students consistently state that pharmacology is an area with which theyneed assistance. The 2016 NCLEX-RN test plan continues to incorporate pharmacology in the exam- ination, but only the generic drug names will be included. Therefore, pharmacology chapters have been included for your review and practice. This book includes 13 pharma- cologychapters,a medication and intravenouscalculation chapter, and a pediatric medication calculation chapter. Each ofthesechaptersisfollowed bya practicetestthatuses the samequestion format described earlier.Thisbook con- tains numerous pharmacology questions. Additionally, more than 900 pharmacology questions can be found on the accompanying Evolve site. How to Use This Book SaundersComprehensiveReviewfortheNCLEX-RN® Examina- tion is especially designed to help you with your successful journey to the peak of the Saunders Pyramid to Success: becoming a registered nurse! As you begin your journey through thisbook,you willbeintroduced to alloftheimpor- tantpointsregardingthe2016 NCLEX-RN examination,the processoftesting,and uniqueand specialtipsregardinghow to prepare yourself for this very important examination. You should begin your process through the Saunders Pyramid to Success by reading all of Unit I in this book xiii Preface
- 16. and becoming familiar with the central points regarding the NCLEX-RN examination. Read Chapter 3, written by a nursing graduate who recently passed the examination, and note what she has to say about the testing experience. Chapter 4 will provide you with the critical testing strate- gies that will guide you in selecting the correct option or assist you in selecting an answer to a question if you must guess. Keep these strategies in mind as you proceed through this book. Continue by studying the specific con- tent areas addressed in Units II through XIX. Review the definitions of the Pyramid Terms located in the Glossary and the Pyramid to Success notes, and identify the Client Needs and Learning Objectives specific to the test plan in each area. Read through the chapters and focus on the Pyramid Points and Pyramid Alerts that identify the areas most likely to be tested on the NCLEX-RN examination. Payparticularattention to thePriorityNursingActionsboxes because theyprovide information about the steps you will take in clinical situations requiring prioritization. As you read each chapter, identify your areas of strength and those in need of further review. Highlight these areas and test your abilities by answering the Crit- ical Thinking: What Should You Do? question and taking all practice tests provided at the end of the chapters. Be sure to review all rationales and test-taking strategies. After reviewing all chapters in the book, turn to Unit XX, the Comprehensive Test. Take this examination and then review each question, answer, and rationale. Identify any areas requiring further review; then take the time to review those areas in both the book and the companion Evolve site. In preparation for the NCLEX-RN examination, be sure to take the pretest and generate your study calendar. Follow the calendar for your review because the calendar represents your pretest results and the best study path to follow based on your strong and weak content areas. Also, be sure to access the Testlets and the Audio Review Summaries as part of your preparation for the NCLEX-RN examination. Climbing the Pyramid to Success The purpose of this book is to provide a comprehen- sive review of the nursing content you will be tested on during the NCLEX-RN examination. However, Saunders Comprehensive Review for the NCLEX-RN® Examination is intended to do morethan simplyprepareyou for the rigors of the NCLEX-RN examination; this book is also meant to serve asa valuable studytool that you can refer to through- out your nursing program, with customizable Evolve site selections to help identify and reinforce key content areas. After using this book for comprehensive content review, your next step on the Pyramid to Success is to get additional practice with a Q&A review product. Saunders Q&A Review for the NCLEX-RN® Examination offers more than 6000 unique practice questions in the book and on the companion Evolve site. The questions are focused on the Client Needs and Integrated Processes of the NCLEX- RN test plan, making it easy to access your study area of choice. For on-the-go Q&Areview, you can pick up Saun- ders Q&AReview Cards for the NCLEX-RN® Examination. Your final step on the Pyramid to Success is to master the online review. SaundersOnline Reviewfor theNCLEX- RN® Examination provides an interactive and individual- ized platform to get you ready for your final licensure exam. This online course provides 10 high-level content modules, supplemented with instructional videos, ani- mations, audio, illustrations, testlets, and several subject matter exams. End-of-module practice tests are provided along with several Crossing the Finish Line practice tests. In addition, you can assess your progress with a pretest, Test Yourself quizzes, and a comprehensive exam in a computerized environment that prepares you for the actual NCLEX-RN examination. At the base of the Pyramid to Success are my test- taking strategies, which provide a foundation for under- standing and unpacking the complexities of NCLEX-RN examination questions, including alternate item formats. Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam takes a detailed look at all of the test-takingstrategiesyou will need to know in order to pass any nursing examination, including the NCLEX-RN. Spe- cial tips are integrated for nursing students, and there are more than 1200 practice questions included so you can apply the testing strategies. Good luck with your journey through the Saunders Pyramid toSuccess. I wish you continued success through- out your new career as a registered nurse! Linda Anne Silvestri xiv Preface
- 17. Acknowledgments Sincere appreciation and warmest thanks are extended to the many individuals who in their own ways have contributed to the publication of this book. First, I want to thank all of my nursing students at the Community College of Rhode Island in Warwick who approached me in 1991 and persuaded me to help them prepare to take the NCLEX-RN® examination. Their enthusiasm and inspiration led to the commencement of my professional endeavors in conducting review courses for the NCLEX-RN examination for nursing stu- dents. I also thank the numerous nursing students who have attended my review courses for their willingness to share their needs and ideas. Their input has certainly added a special uniqueness to this publication. I wish to acknowledge all of the nursing faculty who taught in my review courses for the NCLEX-RN examina- tion. Their commitment, dedication, and expertise have certainly helped nursing students to achieve success with the exam. I want to extend a very special thank you to my niece Dr. Angela Silvestri-Elmore, who functioned as my “super-editor” for this book. In my eyes she is definitely “super,” and her tremendous theoretical and clinical knowledge and expertise and her consistent ideas and input certainly added to the excellent quality of this product. Thank you Angela! I also wish to offer a very special acknowledgment and thank you to Jane Tyerman for reviewing this entire book to ensure that it included Canadian nursing prac- tice and standards. Thank you, Jane! I want to acknowledge and sincerely thank my hus- band, Laurent W. Valliere, or Larry, for his contribution to this publication, for teaching in my review courses for the NCLEX-RN examination, and for his commitment and dedication in helping my nursing students prepare for the NCLEX-RN examination from a nonacademic point of view. Larry has supported my many profes- sional endeavors and was so loyal and loving to me each and every moment as I worked to achieve my profes- sional goals. Larry, thank you so much! And, a special thank you also goes to Jaskaranjeet Bhullar, RN, BSN, for writing a chapter for this book about her experiences preparing for and taking the NCLEX-RN examination. I sincerely acknowledge and thank many very impor- tant individuals from Elsevier who are so dedicated to my work in creating NCLEX products for nursing stu- dents. I thank Yvonne Alexopoulos, Senior Content Strategist, for her continuous assistance, enthusiasm, support, and expert professional guidance as I prepared this publication, and Laurie Gower, Content Develop- ment Manager, for her expert ideas as we planned the project and for her continuous support throughout the production process. And, a special and sincere thank you to Laura Goodrich, Content Development Specialist, for her tremendous amount of support and assistance, for prior- itizing for me to keep me on track, for her ideas for the product, and for her professional and expert skills in organizing and maintaining an enormous amount of manuscript for production. I could not have completed this project without Laura—thank you, Laura! I also want to acknowledge Jamie Randall, Content Strategist for all of her assistance in completing this project— thank you, Jamie! I thank Elodia Dianne Fiorentino for researching content and preparing references for each practice ques- tion; Nicholas Silvestri for editing, formatting, and orga- nizing manuscript files for me; James Guilbault for researching and updating medications; and my personal team who participated in reviewing the Evolve site that accompanies this product. A special thank you to all of you for providing continuous support and dedication to my work in preparing this publication and maintain- ing its excellent quality. I want to acknowledge all of the staff at Elsevier for their tremendous assistance throughout the preparation and production of this publication and all of the Elsevier staff involved in the publication of previous editions of this outstanding NCLEXreview product. Aspecial thank you to all of them. I thank all of the important people in the production and marketingdepartment, includingBill Drone, Book Production Specialist; Danielle LeCompte, Marketing Manager; Jeff Patterson, Publishing Services Manager; Amy Simpson, Multimedia Producer; and Renee Duenow, Designer. And a special thank you to Loren Wilson, former Senior Vice President, for her years of expert guidance xv
- 18. and continuous support for all of the products in the Pyramid to Success. I would also like to acknowledge Patricia Mieg, for- mer educational sales representative, who encouraged me to submit my ideas and initial work for the first edi- tion of this book to the W.B. Saunders Company. A very special and heartfelt thank you goes to my parents, who opened the door of opportunity in educa- tion for me. I thank my mother, Frances Mary, for all of her love, support, and assistance as I continuously worked to achieve my professional goals. I thank my father, Arnold Lawrence, who always provided insightful words of encouragement. My memories of his love and support will always remain in my heart. I am certain that he would be very proud of my professional accomplishments. I also thank my entire family for being continuously supportive, giving, and helpful during my research and preparation of this publication. I want to especially acknowledge each and every individual who contributed to this publication—the reviewers, contributors, item writers, and updaters— for their expert input and ideas. I also thank the many faculty and student reviewers of the manuscript for their thoughts and ideas. A very special thank you to all of you! I also need to thank Salve Regina University for the opportunity to educate nursing students in the baccalau- reate nursing program and for its support during my research and writing of this publication. I would like to especially acknowledge my colleagues Dr. Eileen Gray, Dr. Ellen McCarty, and Dr. Bethany Sykes for all of their encouragement and support. I wish to acknowledge the Community College of Rhode Island, which provided me with the opportunity to educate nursing students in the Associate Degree of Nursing Program. A special thank you goes to Patricia Miller, MSN, RN, and Michelina McClellan, MS, RN, from Baystate Medical Center, School of Nursing, in Springfield, Massachusetts, who were my first mentors in nursing education. Finally, a very special thank you to all of my nursing students—past, present, and future. All of you light up my life! Your love and dedication to the profession of nursing and your commitment to providing health care will bring never-ending rewards! Linda Anne Silvestri xvi Acknowledgments
- 20. CH AP TER 1 The NCLEX-RN® Examination The Pyramid to Success W elcome to the Pyramid to Success Saunders Comprehensive Review for the NCLEX-RN® Examination SaundersComprehensive Reviewfor the NCLEX-RN® Exam- ination is specially designed to help you begin your suc- cessful journey to the peak of the pyramid, becoming a registered nurse. As you begin your journey, you will be introduced to all of the important points regarding the NCLEX-RN examination and the process of testing, and to the unique and special tips regarding how to pre- pare yourself for this important examination. You will read what a nursing graduate who recently passed the NCLEX-RN examination has to say about the test. Important test-taking strategies are detailed. These details will guide you in selecting the correct option or assist you in selecting an answer to a question at which you must guess. Each unit in this book begins with the Pyramid to Success. The Pyramid to Success addresses specific points related to the NCLEX-RN examination. Client Needs as identified in the test plan framework for the examination are listed as well as learning objectives for the unit. Pyr- amid Terms are key words that are defined in the glossary at the end of the book and set in color throughout each chapter to direct your attention to significant points for the examination. Throughout each chapter, you will find Pyramid Point bullets that identify areas most likely to be tested on the NCLEX-RN examination. Read each chapter, and identify your strengths and areas that are in need of fur- ther review. Test your strengths and abilities by taking all practice tests provided in this book and on the accompa- nying Evolve site. Be sure to read all of the rationales and test-taking strategies. The rationale provides you with significant information regarding the correct and incor- rect options. The test-taking strategy provides you with the logical path to selecting the correct option. The test-taking strategy also identifies the content area to review, if required. The reference source and page num- ber are provided so that you can easily find the informa- tion that you need to review. Each question is coded on the basis of the Level of Cognitive Ability, the Client Needs category, the Integrated Process, Priority Con- cepts, and the nursing content area. Saunders Q&A Review for the NCLEX-RN® Examination Following the completion of your comprehensive review in this book, continue on your journey through the Pyr- amid to Success with the companion book, Saunders Q&A Review for the NCLEX-RN® Examination. This book provides you with more than 6000 practice questions in the multiple-choice and alternate item formats, includ- ing audio and video questions. The book is designed based on the NCLEX-RN examination test plan frame- work, with a specific focus on Client Needs and Inte- grated Processes. In addition, each practice question in this book includes a Priority Nursing Tip, which pro- vides you with an important piece of information that will be helpful to answer questions. Then, you will be ready for HESI/Saunders Online Review for the NCLEX- RN® Examination. Additional products in Saunders Pyr- amid to Success include Saunders Strategies for Test Suc- cess: Passing Nursing School and the NCLEX® Exam and Saunders Q&A Review Cards for the NCLEX-RN® Exam. These products are described next. HESI/Saunders Online Review for the NCLEX-RN® Examination This product addresses all areas of the test plan identified by the National Council of State Boards of Nursing (NCSBN). The course contains a pretest that provides feedback regarding your strengths and weaknesses and generates an individualized study schedule in a calendar format. Content review is in an outline format and includes self-check practice questions and testlets (case studies), figures and illustrations, a glossary, and anima- tions and videos. Numerous online exams are included. There are 2500 practice questions; the types of questions in this course include multiple-choice and alternate item formats. Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam This product focuses on the test-taking strategies that will help you to pass your nursing examinations while in nursing school and will prepare you for the NCLEX-RN N C L E X P r e p 2
- 21. examination. The chapters describe various test-taking strategies and include sample questions that illustrate how to use the strategies. Also included in this book is information on cultural characteristics and practices, pharmacology strategies, medication and intravenous calculations, laboratory values, positioning guidelines, and therapeutic diets. This book has more than 1200 practice questions, and each question provides a tip for the beginning nursing student. The practice questions reflect the framework and the content identified in the NCLEX-RN test plan and include multiple-choice and alternate item format questions, including audio and video questions. Saunders Q&A Review Cards for the NCLEX-RN® Exam This product is organized by content area and the frame- work of the NCLEX-RN test plan. It provides you with 1200 unique practice test questions on portable and easy-to-use cards. The cards have the question on the front of the card, and the answer, rationale, and test-taking strategy are on the back of the card. This product includes multiple-choice questions and alternate item format questions, including fill-in-the-blank, multiple-response, ordered-response, figure, and chart/exhibit questions. Saunders RNtertainment for the NCLEX-RN® Exam RNtertainment: The NCLEX® Review Game, 2nd Edition is a revolutionary board game that offers nursing stu- dents a fun and challenging change of pace from stan- dard review options. 800 clinical questions and scenarios cover all the major nursing categories on the NCLEX® test plan—including Health Promotion and Maintenance, Physiological Integrity, Psychosocial Integrity, and Safe and Effective Care Environment. This completely redesigned second edition also features new alternate item formats, test-taking tips and test-taking traps covering helpful test taking strategies and tech- niques, and a rationales booklet that provides justifica- tion for correct answers. All products in the Saunders Pyramid to Success can be obtained online by visiting http://elsevierhealth.com or by calling 800-545-2522. Let’s begin our journey through the Pyramid to Success. Examination Process An important step in the Pyramid to Success is to become as familiar as possible with the examination process. Candidates facing the challenge of this exami- nation can experience significant anxiety. Knowing what the examination is all about and knowing what you will encounter during the process of testing will assist in alle- viating fear and anxiety. The information contained in this chapter was obtained from the NCSBN Web site (http://www.ncsbn.org) and from the NCSBN 2016 test plan for the NCLEX-RN and includes some procedures related to registering for the exam, testing procedures, and the answers to the questions most commonly asked by nursing students and graduates preparing to take the NCLEX. You can obtain additional information regard- ing the test and its development by accessing the NCSBN Web site and clicking on the NCLEXExam tab or by writ- ing to the National Council of State Boards of Nursing, 111 East Wacker Drive, Suite 2900, Chicago, IL 60601. You are encouraged to access the NCSBN Web site because this site provides you with valuable information about the NCLEX and other resources available to an NCLEX candidate. Computer Adaptive Testing The acronym CAT stands for computer adaptive test, which means that the examination is created as the test-taker answers each question. All the test questions are categorized on the basis of the test plan structure and the level of difficulty of the question. As you answer a question, the computer determines your competency based on the answer you selected. If you selected a cor- rect answer, the computer scans the question bank and selects a more difficult question. If you selected an incor- rect answer, the computer scans the question bank and selects an easier question. This process continues until all test plan requirements are met and a reliable pass- or-fail decision is made. When taking a CAT, once an answer is recorded, all subsequent questions administered depend, to an extent, on the answer selected for that question. Skip- ping and returning to earlier questions are not compat- ible with the logical methodology of a CAT. The inability to skip questions or go back to change previous answers will not be a disadvantage to you; you will not fall into that “trap” of changing a correct answer to an incorrect one with the CAT system. If you are faced with a question that contains unfa- miliar content, you may need to guess at the answer. There is no penalty for guessing but you need to make an educated guess. With most of the questions, the answer will be right there in front of you. If you need to guess, use your nursing knowledge and clinical expe- riences to their fullest extent and all of the test-taking strategies you have practiced in this review program. You do not need any computer experience to take this examination. A keyboard tutorial is provided and administered to all test-takers at the start of the examina- tion. The tutorial will instruct you on the use of the on- screen optional calculator, the use of the mouse, and how to record an answer. The tutorial provides instruc- tions on how to respond to all question types on this examination. This tutorial is provided on the NCSBN Web site, and you are encouraged to view the tutorial 3 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 22. when you are preparing for the NCLEX examination. In addition, at the testing site, a test administrator is present to assist in explaining the use of the computer to ensure your full understanding of how to proceed. Development of the Test Plan The test plan for the NCLEX-RN examination is devel- oped by the NCSBN. The examination is a national examination; the NCSBN considers the legal scope of nursing practice as governed by state laws and regula- tions, including the Nurse Practice Act, and uses these laws to define the areas on the examination that will assess the competence of the test-taker for licensure. The NCSBN also conducts an important study every 3 years, known as a practice analysis study, to determine the framework for the test plan for the examination. The participants in this study include newly licensed regis- tered nurses from all types of basic nursing education programs. From a list of nursing care activities provided, the participants are asked about the frequency and importance of performing them in relation to client safety and the setting in which they are performed. A panel of content experts at the NCSBN analyzes the results of the study and makes decisions regarding the test plan framework. The results of this recently con- ducted study provided the structure for the test plan implemented in April 2016. Test Plan The content of the NCLEX-RN examination reflects the activities identified in the practice analysis study con- ducted by the NCSBN. The questions are written to address Level of Cognitive Ability, Client Needs, and Integrated Processes as identified in the test plan devel- oped by the NCSBN. Level of Cognitive A bility Levels of cognitive ability include knowledge, under- standing, applying, analyzing, synthesizing, evaluating, and creating. The practice of nursing requires complex thought processing and critical thinking in decision mak- ing. Therefore, you will not encounter any knowledge or understanding questions on the NCLEX. Questions on this examination are written at the applying level or at higher Levels of Cognitive Ability. Box 1-1 presents an example of a question that requires you to apply data. Client Needs The NCSBN identifies a test plan framework based on Client Needs, which includes 4 major categories. Some of these categories are divided further into subcategories. The Client Needs categories are Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity (Table 1-1). Safe and Effective Care Environment The Safe and Effective Care Environment category includes 2 subcategories: Management of Care, and Safety and Infection Control. According to the NCSBN, Management of Care (17% to 23% of questions) addresses prioritizing content and content that will ensure a safe care delivery setting to protect clients, fam- ilies, significant others, visitors, and health care person- nel. The NCSBN indicates that Safety and Infection Control (9% to 15% of questions) addresses content that will protect clients, families, significant others, vis- itors, and health care personnel from health and envi- ronmental hazards within health care facilities and in community settings. Box 1-2 presents examples of ques- tions that address these 2 subcategories. BOX 1-1 Level of Cognitive Ability: Applying The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these find- ings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration. Answer: 1 This question requires that you focus on the data in the ques- tion and determine that the client is experiencing an infiltra- tion. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IVto prevent any further damage. TABLE 1-1 Client Needs Categories and Percentage of Questions on the NCLEX-RN Examination Client Needs Category Percentage of Questions Safe and Effective Care Environment Management of Care 17-23 Safety and Infection Control 9-15 Health Promotion and Maintenance 6-12 Psychosocial Integrity 6-12 Physiological Integrity Basic Care and Comfort 6-12 Pharmacological and Parenteral Therapies 12-18 Reduction of Risk Potential 9-15 Physiological Adaptation 11-17 4 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 23. Health Promotion and Maintenance The Health Promotion and Maintenance category (6% to 12% of questions) addresses the principles related to growth and development. According to the NCSBN, this Client Needs category also addresses content required to assist the client, family members, and signif- icant others to prevent health problems; to recognize alterations in health; and to develop health practices that promote and support wellness. See Box 1-3 for an example of a question in this Client Needs category. Psychosocial Integrity The Psychosocial Integrity category (6% to 12% of ques- tions) addresses content required to promote and sup- port the ability of the client, client’s family, and client’s significant other to cope, adapt, and problem- solve during stressful events. The NCSBN also indicates that this Client Needs category addresses the emotional, mental, and social well-being of the client, family, or sig- nificant other, and care for the client with an acute or chronic mental illness. See Box 1-4 for an example of a question in this Client Needs category. Physiological Integrity The Physiological Integrity category includes 4 subcat- egories: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and BOX 1-2 Safe and Effective Care Environment Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin before breakfast 2. The client who has a nasogastric tube attached to intermit- tent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of blurred vision Answer: 4 This question addresses the subcategory Management of Care in the Client Needs categorySafe and Effective Care Envi- ronment. Note the strategic word, first, so you need to estab- lish priorities by comparing the needs of each client and deciding which need is urgent. The client described in the cor- rect option has a lowblood glucose leveland symptoms reflec- tive of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1, 2, and 3 have needs that require assessment, their assessments can wait until the client in the correct option is stabilized. Safety and Infection Control The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin- resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheos- tomy attached to a mechanical ventilator, which requires fre- quent suctioning. The nurse should assemble which necessary protective items before entering the client’s room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors Answer: 3 This question addresses the subcategory Safety and Infection Control in the Client Needs category Safe and Effective Care Environment. It addresses content related to protecting one- self from contracting an infection and requires that you con- sider the methods of possible transmission of infection, based on the client’s condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct. BOX 1-3 Health Promotion and Maintenance The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures Answer: 3 This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Note the strategic word, best. Toddlers like to master activities indepen- dently, such as stacking blocks. Because toddlers do not have the developmental abilityto determine what could be harmful, toys that are safe need to be provided. A puzzle and toy sol- diers provide objects that can be placed in the mouth and maybe harmful for a toddler. Acard game with large pictures may require cooperative play, which is more appropriate for a school-age child. BOX 1-4 Psychosocial Integrity A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. “This will help only if I play music at the same time.” 2. “This will work for me only if I am alone in a quiet area.” 3. “I need to do this onlywhen I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Answer: 4 This question addresses the Client Needs category Psychoso- cial Integrity and the content addresses coping mechanisms. Guided imagery involves the client creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation tech- niques or play music with it. 5 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 24. Physiological Adaptation. The NCSBN describes these subcategories as follows. Basic Care and Comfort (6% to 12% of questions) addresses content for providing comfort and assistance to the client in the performance of activities of daily living. Pharmacological and Par- enteral Therapies (12% to 18% of questions) addresses content for administering medications and parenteral therapies such as intravenous therapies and parenteral nutrition, and administering blood and blood products. Reduction of Risk Potential (9% to 15% of questions) addresses content for preventing complications or health problems related to the client’s condition or any prescribed treatments or procedures. Physiological Adaptation (11% to 17% of questions) addresses content for providing care to clients with acute, chronic, or life-threatening conditions. See Box 1-5 for examples of questions in this Client Needs category. Integrated Processes The NCSBN identifies 5 processes in the test plan that are fundamental to the practice of nursing. These processes are incorporated throughout the major categories of Cli- ent Needs. The Integrated Process subcategories are Car- ing, Communication and Documentation, Nursing BOX 1-5 Physiological Integrity Basic Care and Comfort Aclient with Parkinson’s disease develops akinesia while ambu- lating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciouslythink about walking over imaginarylines on the floor. Answer: 4 This question addresses the subcategory Basic Care and Com- fort in the Client Needs category Physiological Integrity, and addresses client mobility and promoting assistance in an activ- ityofdailyliving to maintain safety. Clients with Parkinson’s dis- ease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe. Pharmacological and Parenteral Therapies The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception Answer: 1 This question addresses the subcategory Pharmacological and Parenteral Therapies in the Client Needs categoryPhysiological Integrity. Note the strategic word, early. Digoxin is a cardiac gly- coside that is used to manage and treat heart failure and to con- trol ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointesti- nal disturbances such as anorexia, nausea, and vomiting. Neu- rological abnormalities can also occur earlyand include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personalitychanges, and ocular distur- bances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs. Reduction of Risk Potential Amagnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should imple- ment which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nilper os;nothing bymouth) for 6 hours before the test. 4. Instruct the client in inhalation techniques for the adminis- tration of the radioisotope. Answer: 2 This question addresses the subcategory Reduction of Risk Potential in the Client Needs category Physiological Integrity, and the nurse’s responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequencypulses in a mag- netic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a historyshould be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. NPO status is not necessary for an MRI study of the head. The groin may be shaved for an angio- gram, and inhalation of the radioisotope maybe prescribed with other types ofscans but is not a part ofthe procedures for an MRI. Physiological Adaptation A client with renal insufficiency has a magnesium level of 3.5 mEq/L(1.75 mmol/L). On the basis of this laboratoryresult, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity Answer: 2 This question addresses the subcategory Physiological Adap- tation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. The normal magnesium level is 1.5 to 2.5 mEq/L(0.75 to 1.25 mmol/L). Amagnesium level of 3.5 mEq/L(1.75 mmol/L) indicates hyper- magnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, leth- argy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur. 6 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 25. Process(Assessment,Analysis,Planning,Implementation, and Evaluation), Culture and Spirituality, and Teaching and Learning. See Box 1-6 for an example of a question that incorporates the Integrated Process of Caring. Types of Questions on the Examination The types of questions that may be administered on the examination include multiple-choice; fill-in-the-blank; multiple-response; ordered-response (also known as drag and drop); questions that contain a figure, chart/exhibit, or graphic option item; and audio or video item formats. Some questions may require you to use the mouse and cursor on the computer. For example, you may be pre- sented with a picture that displays the arterial vessels of an adult client. In this picture, you may be asked to “point and click” (using the mouse) on the area (hot spot) where the dorsalis pedis pulse could be felt. In all types of ques- tions, the answer is scored as either right or wrong. Credit is not given for a partially correct answer. In addition, all question types may include pictures, graphics, tables, charts, sound, or video. The NCSBN provides specific directions for you to follow with all question types to guide you in your process of testing. Be sure to read these directions as they appear on the computer screen. Exam- ples of some of these types of questions are noted in this chapter. All question types are provided in this book and on the accompanying Evolve site. Multiple-Choice Questions Many of the questions that you will be asked to answer will be in the multiple-choice format. These questions provide you with data about a client situation and 4 answers, or options. Fill-in-the-Blank Questions Fill-in-the-blank questions may ask you to perform a medication calculation, determine an intravenous flow rate, or calculate an intake or output record on a client. You will need to type only a number (your answer) in the answer box. If the question requires rounding the answer, this needs to be performed at the end of the cal- culation. The rules for rounding an answer are described in the tutorial provided by the NCSBN, and are also pro- vided in the specific question on the computer screen. In addition, you must type in a decimal point if necessary. See Box 1-7 for an example. Multiple-Response Questions For a multiple-response question, you will be asked to select or check all of the options, such as nursing interven- tions, that relate to the information in the question. In these question types, there may be 2 or more correct answers. No partial credit is given for correct selections. You need to do exactly as the question asks, which will be to select all of the options that apply. See Box 1-8 for an example. Ordered-Response Questions In this type of question, you will be asked to use the com- puter mouse to drag and drop your nursing actions in order of priority. Information will be presented in a question and, based on the data, you need to determine what you will do first, second, third, and so forth. The unordered options will be located in boxes on the left side of the screen, and you need to move all options in order of priority to ordered-response boxes on the BOX 1-6 Integrated Processes A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic? 1. “Can you tell me what you understand about the procedure?” 2. “Your fears are a sign that you really should have this procedure.” 3. “Those are very normal fears, but please be assured that everything will be okay.” 4. “Try not to worry. This is a well-known and easy procedure for the health care provider.” Answer: 1 This question addresses the subcategory Caring in the cate- goryIntegrated Processes. The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the proce- dure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold. Option 4 diminishes the client’s feelings bydirecting attention awayfrom the client and toward the health care provider’s importance. BOX 1-7 Fill-in-the-Blank Question A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/15 mL. The nurse prepares how many milliliters to administer 1dose? Fill in the blank. Record your answer using one decimal place. Answer: 19.5 mL Formula: Desired Available  volume¼ mL 650 mg 500 mg  15 mL¼ 19:5 mL In this question, you need to use the formula for calculat- ing a medication dose. When the dose is determined, you will need to type your numeric answer in the answer box. Always follow the specific directions noted on the computer screen. Also, remember that there will be an on-screen calculator on the computer for your use. 7 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 26. right side of the screen. Specific directions for moving the options are provided with the question. See Figure 1-1 for an example. Examples of this question type are located on the accompanying Evolve site. Figure Questions Aquestion with a picture or graphic will ask you to answer the question based on the picture or graphic. The ques- tion could contain a chart, a table, or a figure or illustra- tion. You also may be asked to use the computer mouse to point and click on a specific area in the visual. Afigure or illustration may appear in any type of question, including a multiple-choice question. See Box 1-9 for an example. Chart/Exhibit Questions In this type of question, you will be presented with a problem and a chart or exhibit. You will be provided with 3 tabs or buttons that you need to click to obtain the information needed to answer the question. A prompt or message will appear that will indicate the need to click on a tab or button. See Box 1-10 for an example. Graphic Option Questions In this type of question, the option selections will be pic- tures rather than text. Each option will be preceded by a circle, and you will need to use the computer mouse to click in the circle that represents your answer choice. See Box 1-11 for an example. A udio Questions Audio questionswillrequire listeningto a sound to answer the question. These questions will prompt you to use the headset provided and to click on the sound icon. You will be able to click on the volume button to adjust the volume to your comfort level, and you will be able to listen to the BOX 1-8 Multiple-Response Question The emergency department nurse is caring for a child sus- pected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor. In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the information in the question. To answer this question, recall that acute epiglottitis is a serious obstructive inflamma- toryprocess that requires immediate intervention and that air- way patency is a priority. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate fur- ther obstruction. Alateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on an oxygen saturation monitor to monitor oxygena- tion status. Tracheostomyand intubation maybe necessaryif respiratorydistress is severe. Remember to follow the specific directions given on the computer screen. FIGURE 1-1 Example of an ordered-response question. 8 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 27. sound as many times as necessary. Content examples include, but are not limited to, various lung sounds, heart sounds, or bowel sounds. Examples of this question type are located on the accompanying Evolve site (Fig. 1-2). V ideo Questions Video questions will require viewing of an animation or video clip to answer the question. These questions will prompt you to click on the video icon. There may be sound associated with the animation and video, in which case you will be prompted to use the headset. BOX 1-9 Figure Question A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action? 1. Takes the client’s blood pressure 2. Initiates cardiopulmonary resuscitation (CPR) 3. Places a nitroglycerin tablet under the client’s tongue 4. Continues to monitor the client and then contacts the health care provider (HCP) Answer: 2 This question requires you to identify the cardiac rhythm, and then determine the priority nursing action. Note the strategic word, immediately. This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The HCP or an Advanced Cardiac Life Support (ACLS)–qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4 are incorrect actions and delay life-saving treatment. BOX 1-10 Chart/Exhibit Question Client’s Chart History and physical Medications Diagnostic results Item 1: Has renal calculi Item 2: Had throm- bophlebitis 1 year ago Item 3: Multivita- min orally daily Item 4: Electrocar- diogram normal The nurse reviews the history and physical examination documented in the medical record of a client requesting a pre- scription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? Refer to chart. Answer: 2 This chart/exhibit question provides you with data from the cli- ent’s medical record and asks you to identify the item that is a contraindication to the use of oral contraceptives. Oral contra- ceptives are contraindicated in women with a history of any of the following: thrombophlebitis and thromboembolic disor- ders, cardiovascular or cerebrovascular diseases (including stroke), any estrogen-dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver function, hypertension, and diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficialand deep venous thrombosis, pulmonaryembolism, thrombotic stroke (or other types ofstrokes), myocardialinfarc- tion, and accelerations of preexisting breast tumors. BOX 1-11 Graphic Options Question The nurse should place the client in which position to admin- ister an enema? (Refer to the figures in 1 to 4.) 1. 2. 3. 4. Answer: 2 This question requires you to select the picture that represents your answer choice. To administer an enema, the nurse assists the client into the left side-lying (Sims’) position with the right knee flexed. This position allows the enema solution to flow downward bygravityalong the natural curve of the sig- moid colon and rectum, improving the retention of solution. Option 1 is a prone position. Option 3 is a dorsal recumbent position. Option 4 is a supine position. 9 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 28. Content examples include, but are not limited to, assess- ment techniques, nursing procedures, or communica- tion skills. Examples of this question type are located on the accompanying Evolve site (Fig. 1-3). Registering to Take the Examination It is important to obtain an NCLEX Examination Candi- date Bulletin from the NCSBN Web site at www.ncsbn. org because this bulletin provides all of the information you need to register for and schedule your examination. It also provides you with Web site and telephone informa- tion for NCLEX examination contacts. The initial step in the registration process is to submit an application to the state board of nursing in the state in which you intend to obtain licensure. You need to obtain information from the board of nursing regarding the specific registration process because the process may vary from state to state. Then, use the NCLEXExamination Candidate Bulletin as your guide to complete the registration process. Following the registration instructions and complet- ing the registration forms precisely and accurately are important. Registration forms not properly complet- ed or not accompanied by the proper fees in the required method of payment will be returned to you and will delay testing. You must pay a fee for taking the examination; you also may have to pay additional fees to the board of nursing in the state in which you are applying. Authorization to Test Form and Scheduling an Appointment Once you are eligible to test, you will receive an Autho- rization to Test (ATT) form. You cannot make an appointment until you receive an ATT form. Note the validity dates on the ATT form, and schedule a testing date and time before the expiration date on the ATT form. The NCLEX Examination Candidate Bulletin pro- vides you with the directions for scheduling an appoint- ment and you do not have to take the examination in the same state in which you are seeking licensure. The ATT form contains important information, including your test authorization number, candidate identification number, and validity date. You need to take your ATT form to the testing center on the day of your examination. You will not be admitted to the exam- ination if you do not have it. Changing Your Appointment If for any reason you need to change your appointment to test, you can make the change on the candidate Web site or bycallingcandidate services. Refer to the NCLEXExamina- tion Candidate Bulletin for this contact information and other important procedures for canceling and changing an appointment. If you fail to arrive for the examination FIGURE 1-2 Example of an audio question. 10 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 29. or fail to cancel your appointment to test without provid- ing appropriate notice, you will forfeit your examination fee and your ATT form will be invalidated. This informa- tion will be reported to the board of nursing in the state in which you have applied for licensure, and you will be required to register and pay the testing fees again. Day of the Examination It is important that you arrive at the testing center at least 30 minutesbefore the test isscheduled. Ifyou arrive late for the scheduled testing appointment, you may be required to forfeit your examination appointment. If it is necessary to forfeit your appointment, you will need to reregister for the examination and pay an additional fee. The board of nursing will be notified that you did not take the test. A few days before your scheduled date of testing, take the time to drive to the testing center to determine its exact location, the length of time required to arrive at that des- tination, and any potential obstacles that might delay you, such as road construction, traffic, or parking sites. In addition to the ATT form, you must have proper identification (ID) such as a U.S. driver’s license, pass- port, U.S. state ID, or U.S. military ID to be admitted to take the examination. All acceptable identification must be valid and not expired and contain a photograph and signature (in English). In addition, the first and last names on the ID must match the ATTform. According to the NCSBN guidelines, any name discrepancies require legal documentation, such as a marriage license, divorce decree, or court action legal name change. Testing Accommodations If you require testing accommodations, you should con- tact the board of nursing before submitting a registration form. The board ofnursingwill provide the proceduresfor the request. The board of nursing must authorize testing accommodations. Following board of nursing approval, the NCSBN reviews the requested accommodations and must approve the request. If the request is approved, the candidate will be notified and provided the procedure for registering for and scheduling the examination. Testing Center The testing center is designed to ensure complete security of the testing process. Strict candidate identification requirements have been established. You will be asked to read the rules related to testing. A digital fingerprint and palm vein print will be taken. Adigital signature and pho- tograph will also be taken at the testing center. These iden- tity confirmations will accompany the NCLEX exam results.In addition,ifyou leavethetestingroom foranyrea- son, you may be required to perform these identity confir- mation procedures again to be readmitted to the room. Personal belongings are not allowed in the testing room; all electronic devices must be placed in a sealable FIGURE 1-3 Example of a video question. 11 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 30. bag provided by the test administrator and kept in a locker. Any evidence of tampering with the bag could result in an incident and a result cancellation. A locker and locker key will be provided for you; however, storage space is limited, so you must plan accordingly. In addi- tion, the testing center will not assume responsibility for your personal belongings. The testing waiting areas are generally small; friends or family members who accom- pany you are not permitted to wait in the testing center while you are taking the examination. Once you have completed the admission process, the test administrator will escort you to the assigned com- puter. You will be seated at an individual workspace area that includes computer equipment, appropriate lighting, an erasable note board, and a marker. No items, including unauthorized scratch paper, are allowed into the testing room. Eating, drinking, or the use of tobacco is not allowed in the testing room. You will be observed at all times by the test administrator while taking the examina- tion. In addition, video and audio recordingsofall test ses- sions are made. The testing center has no control over the soundsmade bytypingon the computer byothers. Ifthese soundsare distracting, raise your hand to summon the test administrator. Earplugs are available on request. You must follow the directions given by the testingcen- ter staff and must remain seated during the test except when authorized to leave. If you think that you have a problem with the computer, need a clean note board, need to take a break, or need the test administrator for any rea- son, you must raise your hand. You are also encouraged to access the NCSBN candidate Web site to obtain additional information about the physical environment of the testing center and to view a virtual tour of the testing center. Testing Time The maximum testing time is 6 hours; this period includes the tutorial, the sample items, all breaks, and the examination. All breaks are optional. The first optional break will be offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. Remember that all breaks count against testing time. If you take a break, you must leave the testing room and, when you return, you may be required to perform identity confirmation procedures to be readmitted. Length of the Examination The minimum number of questions that you will need to answer is 75. Ofthese 75 questions, 60 will be operational (scored) questions and 15 will be pretest (unscored) questions. The maximum number of questions in the test is 265. Fifteen of the total number of questions that you need to answer will be pretest (unscored) questions. The pretest questions are questions that may be pre- sented as scored questions on future examinations. These pretest questions are not identified as such. In other words, you do not know which questions are the pretest (unscored) questions; however, these pretest (unscored) questions will be administered among the first 75 questions in the test. Pass-or-Fail Decisions All examination questions are categorized by test plan area and level of difficulty. This is an important point to keep in mind when you consider how the computer makes a pass-or-fail decision because a pass-or-fail decision is not based on a percentage of correctly answered questions. The NCSBN indicates that a pass-or-fail decision is governed by 3 different scenarios. The first scenario is the 95% Confidence Interval Rule, in which the com- puter stops administering test questions when it is 95% certain that the test-taker’s ability is clearly above the passing standard or clearly below the passing stan- dard. The second scenario is known as the Maximum- Length Exam, in which the final ability estimate of the test-taker is considered. If the final ability estimate is above the passing standard, the test-taker passes; if it is below the passing standard, the test-taker fails. The third scenario is the Run-Out-Of-Time (R.O.O.T) Rule. If the examination ends because the test-taker ran out of time, the computer may not have enough informa- tion with 95% certainty to make a clear pass-or-fail deci- sion. If this is the case, the computer will review the test-taker’s performance during testing. If the test-taker has not answered the minimum number ofrequired ques- tions, the test-taker fails. If the test-taker’s ability estimate was consistently above the passing standard on the last 60 questions, the test-taker passes. If the test-taker’s ability estimate falls below the passing standard, even once, the test-taker fails. Additional information about pass- or-fail decisions can be found in the NCLEXExamination Candidate Bulletin located at www.ncsbn.org. Completing the Examination When the examination has ended, you will complete a brief computer-delivered questionnaire about your testing experience. After you complete this question- naire, you need to raise your hand to summon the test administrator. The test administrator will collect and inventory all note boards and then permit you to leave. Processing Results Every computerized examination is scored twice, once by the computer at the testing center and again after the examination is transmitted to the test scoring center. No results are released at the testing center; testing center staff do not have access to examination results. The board of nursing receives your result and your result will 12 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 31. be mailed to you approximately 1 month after you take the examination. In some states, an unofficial result can be obtained via the Quick Results Service 2 business days after taking the examination. There is a fee for this service and information about obtaining your NCLEXresult by this method can be obtained on the NCSBN Web site under candidate services. Candidate Performance Report Acandidate performance report is provided to a test-taker who failed the examination. This report provides the test- taker with information about her or his strengths and weaknessesin relation to the test plan framework and pro- vides a guide for studyingand retakingthe examination. If a retake is necessary, the candidate must wait 45 to 90 days between examination administration, depending on state procedures. Test-takers should refer to the state board of nursing in the state in which licensure is sought for proce- dures regardingwhen the examination can be taken again. Interstate Endorsement Because the NCLEX-RN examination is a national exam- ination, you can apply to take the examination in any state. When licensure is received, you can apply for inter- state endorsement, which is obtaining another license in another state to practice nursing in that state. The pro- cedures and requirements for interstate endorsement may vary from state to state, and these procedures can be obtained from the state board of nursing in the state in which endorsement is sought. Nurse Licensure Compact It may be possible to practice nursing in another state under the mutual recognition model of nursing licensure if the state has enacted a Nurse Licensure Compact. To obtain information about the Nurse Licensure Compact and the states that are part of this interstate compact, access the NCSBN Web site at http://www.ncsbn.org. The Foreign-Educated Nurse An important first step in the process of obtaining infor- mation about becoming a registered nurse in the United States is to access the NCSBN Web site at http://www. ncsbn.org and obtain information provided for interna- tional nurses in the NCLEX Web site link. The NCSBN provides information about some of the documents you need to obtain as an international nurse seeking licensure in the United States and about credentialing agencies. Refer to Box 1-12 for a listing of some of these documents. The NCSBN also provides information regarding the requirements for education and English proficiency, and immigration requirements such as visas and VisaScreen. You are encouraged to access the NCSBN Web site to obtain the most current information about seekinglicensure as a registered nurse in the United States. An important factor to consider as you pursue this process is that some requirements may vary from state to state. You need to contact the board of nursing in the state in which you are planning to obtain licensure to determine the specific requirements and documents that you need to submit. Boards of nursing can decide either to use a credential- ing agency to evaluate your documents or to review your documents at the specific state board, known as in-house evaluation. When you contact the board of nursing in the state in which you intend to work as a nurse, inform them that you were educated outside of the United States and ask that theysend you an application to applyfor licensure by examination. Be sure to specify that you are applying for registered nurse (RN) licensure. You should also ask about the specific documents needed to become eligible to take the NCLEXexam. You can obtain contact informa- tion for each state board of nursing through the NCSBN Web site at http://www.ncsbn.org. In addition, you can write to the NCSBN regarding the NCLEX exam. The address is 111 East Wacker Drive, Suite 2900, Chicago, IL 60601. The telephone number for the NCSBN is 1-866-293-9600; international telephone is 011 1 312 525 3600; the fax number is 1-312-279-1032. BOX 1-12 Foreign-Educated Nurse: Some Documents Needed to Obtain Licensure 1. Proof of citizenship or lawful alien status 2. Work visa 3. VisaScreen certificate 4. Commission on Graduates of Foreign Nursing Schools (CGFNS) certificate 5. Criminal background check documents 6. Official transcripts of educational credentials sent directly to credentialing agency or board of nursing from home country school of nursing 7. Validation of a comparable nursing education as that pro- vided in U.S. nursing programs;this mayinclude theoretical instruction and clinicalpractice in a varietyofnursing areas, including, but not limited to, medicalnursing, surgicalnurs- ing,pediatric nursing,maternityand newborn nursing,com- munityand publichealth nursing,and mentalhealth nursing 8. Validation of safe professional nursing practice in home country 9. Copy of nursing license or diploma or both 10. Proof of proficiency in the English language 11. Photograph(s) 12. Social Security number 13. Application and fees 13 CHAPTER 1 The NCLEX-RN® Examination N C L E X P r e p
- 32. CH AP TER 2 Pathways to Success Laurent W. Valliere, BS, DD The Pyramid to Success Preparing to take the NCLEX-RN® examination can pro- duce a great deal of anxiety. You may be thinking that this exam is the most important one you will ever have to take and that it reflects the culmination of everything you have worked so hard for. This is an important exam- ination because receiving your nursing license means that you can begin your career as a registered nurse. Your success on this exam involves getting rid of all thoughts that allow this examination to appear overwhelming and intimidating. Such thoughts can take complete control over your destiny. A strong positive attitude, a structured plan for preparation, and maintaining con- trol in your pathway to success ensure reaching the peak of the Pyramid to Success (Fig. 2-1). Pathways to Success (Box 2-1) Foundation The foundation of pathways to success begins with a strong positive attitude, the belief that you will achieve success, and developing control. It also includes develop- ing a list of your personal short-term and long-term goals and a plan for preparation. Without these components, your pathway to success leads to nowhere and has no endpoint. You will expend energy and valuable time in your journey, lack control over where you are heading, and experience exhaustion without any accomplishment. Where do you start? To begin, find a location that offers solitude. Sit or lie in a comfortable position, close your eyes, relax, inhale deeply, hold your breath to a count of 4, exhale slowly, and, again, relax. Repeat this breathing exercise several times until you feel relaxed, free from anxiety, and in control of your destiny. Allow your mind to become void of all mind chatter; now you are in control and your mind’s eye can see for miles. Next, reflect on all that you have accomplished and the path that brought you to where you are today. Keep a journal of your reflections as you plan the order of your journey through the Pyramid to Success. List It is time to create the “List.” The List is your set of short- term and long-term goals. Begin by developing the goals that you wish to accomplish today, tomorrow, over the next month, and in the future. Allow yourself the oppor- tunity to list all that is flowing from your mind. Write your goals in your personal journal. When the List is complete, put it away for 2 or 3 days. After that time, retrieve and review the List and begin the process of planning to prepare for the NCLEX-RN exam. Plan for Preparation Now that you have the List in order, look at the goals that relate to studying for the licensing exam. The first task is to decide what study pattern works best for you. Think about what has worked most successfully for you in the past. Questions that must be addressed to develop your plan for study are listed in Box 2-2. The plan must include a schedule. Use a calendar to plan and document the daily times and nursing content areas for your study sessions. Establish a realistic sched- ule that includes your daily, weekly, and future goals, and stick to your plan of study. This consistency will provide advantages to you and the people supporting you. You will develop a rhythm that can enhance your retention and positive momentum. The people who are supporting you will share this rhythm and be able to schedule their activities and lives better when you are consistent with your study schedule. The length of the study session depends on your abil- ity to focus and concentrate. You need to think about quality rather than quantity when you are deciding on a realistic amount of time for each session. Plan to sched- ule at least 2 hours of quality study time daily. If you can spend more than 2 hours, by all means do so. You may ask, “What do you mean by quality study time?” Quality study time means spending uninter- rupted quiet time at your study session. This may mean that you have to isolate yourself for these study sessions. Think again about what has worked for you during nurs- ing school when you studied for examinations; select a study place that has worked for you in the past. If you N C L E X P r e p 14
- 33. have a special study room at home that you have always used, plan your study sessions in that special room. If you have always studied at a library, plan your study ses- sions at the library. Sometimes it is difficult to balance your study time with your family obligations and possi- bly a work schedule, but, if you can, plan your study time when you know that you will be at home alone. Try to eliminate anything that may be distracting during your study time. Silence your cellphone appropriately so that you will not be disturbed. If you have small children, plan your study time during their nap time or during their school hours. Your plan must include how you will manage your study needs with your other obligations. Your family and friends are key players in your life and are going to become part of your Pyramid to Success. After you have established your study needs, communicate your needs and the importance of your study plan to your family and friends. A difficult part of the plan may be how to deal with family members and friends who choose not to partici- pate in your plan for success. For example, what do you do if a friend asks you to go to a movie and it is your scheduled study time? Your friend may say, “Take some time off. You have plenty of time to study. Study later when we get back!” You are faced with a decision. You must weigh all factors carefully. You must keep your goals in mind and remember that your need for positive momentum is critical. Your decision may not be an easy one, but it must be one that will ensure that your goal of becoming a registered nurse is achieved. Positive Pampering Positive pampering means that you must continue to care for yourself holistically. Positive momentum can be maintained only if you are properly balanced. Proper exercise, diet, and positive mental stimulation are crucial to achieving your goal of becoming a registered nurse. Just as you have developed a schedule for study, you should have a schedule that includes fun and physical Control Structured study plan Strong positive attitude Regis tered Nurs e! FIGURE 2-1 Pyramid to Success. BOX 2-1 Pathways to Success Foundation Maintaining a strong positive attitude Thinking about short-term and long-term realistic goals Developing a plan for preparation Maintaining control List Writing short-term and long-term realistic goals in a journal Plan for Preparation Developing a study plan and schedule Deciding on the place to study Balancing personal and work obligations with the study schedule Sharing the study schedule and personal needs with others Implementing the study plan Positive Pampering Planning time for exercise and fun activities Establishing healthy eating habits Including activities in the schedule that provide positive men- tal stimulation Final Preparation Reviewing and identifying goals achieved Remaining focused to complete the plan of study Writing down the date and time of the examination and post- ing it next to your name with the letters “RN” following, and the word “YES!” Planning a test drive to the testing center Engaging in relaxing activities on the day before the examination Day of the Examination Grooming yourself for success Eating a nutritious breakfast Maintaining a confident and positive attitude Maintaining control— breathe and focus Meeting the challenges of the day Reaching the peak of the Pyramid to Success BOX 2-2 Developing a Plan for Study Do I work better alone or in a study group? If I work best in a group, how many study partners should I have? Who are these study partners? How long should my study sessions last? Does the time of day that I study make a difference? Do I retain more if I study in the morning? How does my work schedule affect my study pattern? How do I balance my family obligations with my need to study? Do I have a comfortable study area at home or should I find another environment that is conducive to mystudyneeds? 15 CHAPTER 2 Pathways to Success N C L E X P r e p
- 34. activity. It is your choice—aerobics, walking, weight lift- ing, bowling, or whatever makes you feel good about yourself. Time spent away from the hard study schedule and devoted to some fun and physical exercise pays you back a hundredfold. You will be more energetic with a schedule that includes these activities. Establish healthy eating habits. Be sure to drink plenty of water, which will flush and clean your body cells. Stay away from fatty foods because they slow you down. Eat lighter meals and eat more frequently. Include complex carbohydrates such as oatmeal or whole grain foods in your diet for energy, and be careful not to include too much caffeine in your daily diet. Take the time to pamper yourself with activities that make you feel even better about who you are. Make din- ner reservations at your favorite restaurant with some- one who is special and is supporting your goal. Take walks in a place that has a particular tranquility that enables you to reflect on the positive momentum that you have achieved and maintained. Whatever it is, wher- ever it takes you, allow yourself the time to do some pos- itive pampering. Final Preparation You have established the foundation of your Pyramid to Success. You have developed your list of goals and your study plan, and you have maintained your positive momentum. You are moving forward, and in control. When you receive your date and time for the NCLEX- RN examination, you may immediately think, “I am not ready!” Stop! Reflect on all you have achieved. Think about your goal achievement and the organization of the positive life momentum with which you have sur- rounded yourself. Think about all of the people who love and support your effort to become a registered nurse. Believe that the challenge that awaits you is one that you have successfully prepared for and will lead you to your goal of becoming a registered nurse. Take a deep breath and organize the remaining days so that they support your educational and personal needs. Support your positive momentum with a visual technique. Write your name in large letters, and write the letters “RN” after it. Post 1 or more of these visual reinforcements in areas that you frequent. This is a visual motivational technique that works for many nursing graduates preparing for this examination. It is imperative that you not fall into the trap of expecting too much of yourself. The idea of perfection must not drive you to a point that causes your positive momentum to falter. You must believe and stay focused on your goal. The date and time are at hand. Write the date and time, and underneath write the word “YES!” Post this next to your name plus “RN.” Ensure that you have command over how to get to the testing center. A test run is a must. Time the drive, and allow for road construction or whatever might occur to slow traffic down. On the test run, when you arrive at the test facility, walk into it and become familiar with the lobby and the surroundings. This may help to alleviate some of the peripheral nervousness associated with entering an unknown building. Remember that you must do whatever it takes to keep yourself in control. If familiarizing yourself with the facility will help you to maintain positive momentum, by all means be sure to do so. It is time to check your study plan and make the nec- essary adjustments now that a firm date and time are set. Adjust your review so that your study plan ends 2 days before the examination. The mind is like a muscle. If it is overworked, it has no strength or stamina. Your strat- egy is to rest the body and mind on the day before the examination. Your strategy is to stay in control and allow yourself the opportunity to be absolutely fresh and attentive on the day of the examination. This will help you to control the nervousness that is natural, achieve the clear thought processes required, and feel confident that you have done all that is necessary to prepare for and conquer this challenge. The day before the examina- tion is to be one of pleasure. Treat yourself to what you enjoy the most. Relax! Take a deep breath, hold to a count of 4, and exhale slowly. You have prepared yourself well for the challenge of tomorrow. Allow yourself a restful night’s sleep, and wake up on the day of the examination know- ing that you are absolutely prepared to succeed. Look at your name with “RN” after it and the word “YES!” Day of the Examination (Box 2-3) Wake up believing in yourself and that all you have accomplished is about to propel you to the professional level of registered nurse. Allow yourself plenty of time, eat a nutritious breakfast, and groom yourself for suc- cess. You are ready to meet the challenges of the day and overcome any obstacle that may face you. Today will soon be history, and tomorrow will bring you the enve- lope on which you read your name with the words “Reg- istered Nurse” after it. Be proud and confident of your achievements. You have worked hard to achieve your goal of becoming a BOX 2-3 Day of the Examination Breathe: Inhale deeply, hold your breath to a count of 4, exhale slowly Believe: Have positive thoughts today and keep those thoughts focused on your achievements Control: You are in command Believe: This is your day Visualize: “RN” with your name 16 UNIT I NCLEX-RN® Exam Preparation N C L E X P r e p
- 35. registered nurse. If you believe in yourself and your goals, no one person or obstacle can move you off the pathway that leads to success! Congratulations, and I wish you the very best in your career as a registered nurse! This Is Not a Test 1. What are the factors needed to ensure a productive study environment? Select all that apply. 1. Secure a location that offers solitude. 2. Plan breaks during your study session. 3. Establish a realistic study schedule that includes your goals. 4. Continue with the study pattern that has worked best for you. Answers: 1, 2, 3, 4 Rationale: Alocation of solitude helps to ensure concen- tration. Taking breaks during your study session helps to clear your mind and increase your ability to concentrate and focus. Establishing a realistic study pattern will keep you in control. Do not vary your study pattern. It has been successful for you, so why change now? 2. What are key factors in your final preparation? Select all that apply. 1. Remain focused on the study plan. 2. Visualize the “RN” after your name. 3. Avoid studying on the day before the exam and relax. 4. Know where the testing center is and how long it takes to get there. Answers: 1, 2, 3, 4 Rationale: Focus on your plan of study and success will follow. Positive reinforcement: Write your name in large letters on a piece of paper with “RN” after your name and post it where you will see it often. Allow yourself a day of pampering before the test. Wake up on the day of the test refreshed and ready to succeed. Ensure that you know where the testing center is; map out your route and the average time it takes to arrive. 3. What key points do the “Pathways to Success” empha- size to help ensure your success? Select all that apply. 1. A strong positive attitude 2. Believing in your ability to succeed 3. Being proud and confident in your achievements 4. Maintaining control of your mind, surrounding environment, and physical being Answers: 1, 2, 3, 4 Rationale: A strong positive attitude leads to success. Believe in who you are and the goals you have set for yourself. Be “proud and confident.” If you believe in your- self, you will achieve success. Maintain control and all of your goals are attainable. Your grade: A+ Continue to “Believe” and you will succeed. RN belongs to you! 17 CHAPTER 2 Pathways to Success N C L E X P r e p
- 36. CH AP TER 3 The NCLEX-RN® Examination from a Graduate’s Perspective Jaskaranjeet “Jessica” Bhullar, BSN, RN Graduating from nursing school is a huge accomplish- ment. After earning my Bachelor of Science in Nursing (BSN), I reflected on all of the work that had led to that moment. The past 16 months had been a whirlwind. Memories of preparing for simulations and late nights studying for exams and completing detailed care plans flooded my mind. Though I was done with school, I knew there was one more test I would have to pass before I could call myself a registered nurse. The NCLEX® is a national licensing exam that is adminis- tered to every nursing school graduate. Passing this exam gives graduates a license to practice. I knew it would be the most important exam of my life and I was deter- mined to pass it. In addition to studying, a few things must be done in preparation for the NCLEX. Approximately 1 month before I graduated, I submitted the required paperwork and fees to my State Board of Nursing. It is important to do this well in advance, as it can potentially take months for your state board to process the paperwork. Your school will notify the board once your degree is con- firmed. Then it is a matter of waiting for your Authoriza- tion to Test (ATT). An ATT enables you to schedule your test date. Since I had done everything on my part to ensure that there would be no delays, I expected to receive my ATT within a few weeks after graduation. While I waited, I packed up my apartment and moved from Nevada to my home state of California. I also spent some time catching up with friends I had not seen in months. Within a few days of arriving home, I received myATT. I wanted to take the exam as soon as possible, so I expanded my search for testing centers to neighboring cit- ies. I did not mind driving a bit farther if it meant that I could take the exam sooner. I found that the earliest avail- able test date was 3 weeks later in a city about 45 minutes away. The only available time was 2:00 p.m., which I gladly accepted as it meant I could get a good night’s rest and avoid early morning traffic. I felt that I had a solid knowledge base from school, and 3 weeks would be more than enough time to review concepts and practice more questions. You will need to assess your personal knowledge level and confidence to gauge how much time you require to study. It is recommended to take the exam within a maximum of 3 months to ensure that you are not losing the knowledge you learned while in school. Now that I had a date marked in my calendar, I felt empowered to create a study plan. I chose to use 1 or 2 resources at the most in order to stay focused and mas- ter content realistically. Based on my research, I chose SaundersComprehensive Reviewfor the NCLEX-RN® Exam- ination. I used this text in nursing school and knew it would benefit me during my NCLEX preparation. Be thoughtful and selective when choosing study tools and find what works best for you. What works for some people may not work for others. I set a goal to practice 150 to 200 questions a day. The NCLEX can ask as few as 75 questions and as many as 265. I wanted to build up my test-taking endurance, which is why I chose to practice so many questions. When I answered questions, I would read the entire rationales regardless of whether I answered correctly or not. A wealth of information is included in each rationale. You will gain a better under- standing of not only content, but also why you selected an incorrect or correct answer. It is also important to read the Test-Taking Strategy, because this will provide you with a logical way of answering the question if you were not as confident in your mastery of the material as you would have liked. I prefer to study alone, and I spent most days practicing questions at home or in a nearby cafe. I made sure to take a break every hour to stretch and refresh my mind. Knowing that I had only a few weeks to study made me use my time more wisely. I knew it was only a matter of time before I would be done with the NCLEX, and I wanted to feel as if I had done everything I could to pass the exam. If there is anything you can do to alleviate test anxi- ety, do it! Two days before the exam, I drove to the test- ing center. I left my house around the same time I planned to leave on the actual test day, so I could see N C L E X P r e p 18
- 37. what traffic would be like and the parking availability. I found a market nearby where I planned to have lunch before taking the exam. Simply doing this dry run helped to calm my nerves. I could visualize what my test day would look like. The day before the NCLEX, I chose to relax my mind, so I didn’t practice any questions. I made sure to put my ATTand identification (ID) aside because they are required at check-in and I didn’t want to forget them. I spent the day with my family and went to bed early. Keep in mind that the exam can take as long as 6 hours, so adequate sleep is a must! On the day of the NCLEX, I left my house a few hours early so I would have a chance to eat lunch and practice a few questions, just to get into test-taking mode. I believe that a positive mental attitude is important in life and especially in potentially stressful situations. I knew that in a matter of hours, the exam would be over. It does not matter at what question number your computer turns off, but rather that you answered each question thought- fully and to the best of your ability. I arrived at the testing center 30 minutes early. I was aware that lockers are pro- vided, but I brought as little as possible with me. The check-in process involves showing your ATT and ID, having your fingers and palms scanned, and having your photo taken. You will also be given a form with instruc- tions about the exam, which you will be required to sign. It is all very straightforward. I was directed to a computer in the testing room. I took a deep breath and began the exam. I treated each question as if it was the last one I had to answer. Before I knew it, I was on question number 75 and I clicked submit. The computer shut down and I felt a wave of relief. I was done with the NCLEX! I left the testing center feeling confident. The ques- tions had become difficult very quickly, and I took that as an indication that I was doing well. I replayed the questions in my mind on the drive home, and began to dwell on a couple I had been unsure about. I didn’t allow myself to become consumed by self-doubt because the exam was over and there was nothing I could do but wait! Acouple of days later, I found out I was officially a registered nurse! My lifelong dream was now a reality. I had worked so hard for this, and felt that now I could celebrate with my friends and family. The NCLEX is the last hurdle you will have to jump over before you begin your professional career. It may be tempting to put off taking the test until you feel 100% prepared, but the longer you wait the more likely it is that you will forget content you learned during school. Believe in yourself and your education! Use your time wisely and reduce anxiety however you can. I hope these suggestions will benefit you. Congratulations for all you have and will accomplish, and the best of luck in your new career! 19 CHAPTER 3 The NCLEX-RN® Examination from a Graduate’s Perspective N C L E X P r e p
- 38. N C L E X P r e p CH AP TER 4 Test-Taking Strategies If you would like to read more about test-taking strate- gies after completing this chapter, Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam focuses on the test-taking strategies that will help you to pass your nursing examinations while in nursing school and will prepare you for the NCLEX-RN® examination. I. Key Test-Taking Strategies (Box 4-1) II. How to Avoid Reading into the Question (Box 4-2) A. Pyramid Points 1. Avoid asking yourself the forbidden words, “Well, what if …?” because this will lead you to the “for- bidden” area: reading into the question. 2. Focus only on the data in the question, read every word, and make a decision about what the ques- tion is asking. Reread the question more than 1 time; ask yourself, “What is this question ask- ing?” and “What content is this question test- ing?” (see Box 4-2). 3. Look for the strategic words in the question, such as immediate, initial, first, priority, initial, best, need for follow-up, or need for further teaching; strategic words make a difference regarding what the question is asking. 4. In multiple-choice questions, multiple-response questions, or questions that require you to arrange nursing interventions or other data in order of priority, read every choice or option pre- sented before answering. 5. Always use the process of elimination when choices or options are presented; after you have eliminated options, reread the question before selecting your final choice or choices. Focus on the data in both the question and the options to assist in the process of elimination and direct- ing you to the correct answer (see Box 4-2). 6. With questions that require you to fill in the blank, focus on the data in the question and determine what the question is asking; if the question requires you to calculate a medication dose, an intravenous flow rate, or intake and out- put amounts, recheck your work in calculating and always use the on-screen calculator to verify the answer. B. Ingredients of a question (Box 4-3) 1. The ingredients of a question include the event, which is a client or clinical situation; the event query; and the options or answers. 2. The event provides you with the content about the client or clinical situation that you need to think about when answering the question. 3. The event query asks something specific about the content of the event. 4. The options are all of the answers provided with the question. 5. In a multiple-choice question, there will be 4 optionsand you must select one;read everyoption carefully and think about the event and the event query as you use the process of elimination. 6. In a multiple-response question, there will be several options and you must select all options that apply to the event in the question. Each option provided is a true or false statement; choose the true statements. Also, visualize the event and use your nursing knowledge and clin- ical experiences to answer the question. 7. In an ordered-response (prioritizing)/drag-and- drop question, you will be required to arrange in order of priority nursing interventions or other data; visualize the event and use your nursing knowledge and clinical experiences to answer the question. 8. A fill-in-the-blank question will not contain options, and some figure/illustration questions and audio or video item formats may or may not contain options. A graphic option item will contain options in the form of a picture or graphic. 9. A chart/exhibit question will most likely contain options; read the question carefully and all of the information in the chart or exhibit before select- ing an answer. In this question type, there will be information that is pertinent to how the question is answered, and there may also be information that is not pertinent. It is necessary to discern what information is important and what the “distractors” are. 20
- 39. 10. ATestlet is also known as a Case Study. Informa- tion about a client or event is presented in the testlet followed by several questions that relate to the information. These questions can be in a multiple choice format or an alternate item for- mat. It is important to read all of the data in the question and look for abnormalities in the information presented before answering the accompanying questions. III. Strategic Words (Boxes 4-4 and 4-5) A. Strategic words focus your attention on a critical point to consider when answering the question and will assist you in eliminating the incorrect options. These words can be located in either the event or the query of the question. N C L E X P r e p BOX 4-1 Key Test-Taking Strategies ▪ The Question ▪ Focus on the data, read every word, and make a deci- sion about what the question is asking. ▪ Note the subject and determine what content is being tested. ▪ Visualize the event; note if an abnormality exists in the data provided. ▪ Look for the strategic words; strategic words make a dif- ference regarding what the question is asking about. ▪ Determine if the question presents a positive or nega- tive event query. ▪ Avoid asking yourself, “Well, what if…?” because this will lead you to reading into the question. ▪ The Options ▪ Always use the process of elimination when choices or options are presented and always read each option care- fully; once you have eliminated options, reread the ques- tion before selecting your final choice or choices. ▪ Look for comparable or alike options and eliminate these. ▪ Determine if there is an umbrella option; if so, this could be the correct option. ▪ Identify any closed-ended words; if present, the option is likely incorrect. ▪ Use the ABCs, airway, breathing, and circulation, Maslow’s Hierarchy of Needs, and the steps of the Nursing Process to answer questions that require prioritizing. ▪ Use therapeutic communication techniques to answer communication questions and remember to focus on the client’s thoughts, feelings, concerns, anxieties, and fears. ▪ Use delegating and assignment-making guidelines to match the client’s needs with the scope of practice of the health care provider. ▪ Use pharmacology guidelines to select the correct option if the question addresses a medication. ▪ Determine whether the question is a positive or nega- tive event query. BOX 4-2 Practice Question: Avoiding the “What if …?” Syndrome and Reading into the Question The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action? 1. Administer oxygen to the client 2. Prepare to administer furosemide 3. Elevate the head of the client’s bed 4. Call the health care provider (HCP) Answer: 3 Test-Taking Strategy: You mayimmediatelythinkthat the client has developed pulmonary edema, a complication of heart fail- ure, and needs a diuretic. Although pulmonaryedema is a com- plication ofheart failure, the question does not specificallystate that pulmonary edema has developed, and the client could be experiencing shortness of breath or dyspnea as a symptom of heart failure exacerbation. This is why it is important to base your answer onlyon the information presented, without assum- ing something else could be occurring. Read the question care- fully. Note the strategic word, immediate, and focus on the data in the question, the client’s complaints. An HCP’s prescription is needed to administer oxygen. Although the HCP mayneed to be notified, this is not the immediate action. Furosemide is a diuretic and mayor maynot be prescribed for the client; further data would be needed in order to make this determination. Because there are no data in the question that indicate the pres- ence of pulmonary edema, option 3 is correct. Additionally, focus on what the question is asking. The question is asking you for a nursing action, so that is what you need to look for as you eliminate the incorrect options. Use nursing knowledge and test-taking strategies to assist in answering the question. Remember to focus on the data in the question, focus on what the question is asking, and avoid the “What if …?” syndrome and reading into the question. BOX 4-3 Ingredients of a Question: Event, Event Query, and Options Event: The nurse is caring for a client with terminal cancer. Event Query: The nurse should consider which factor when planning opioid pain relief? Options: 1. Not all pain is real. 2. Opioid analgesics are highly addictive. 3. Opioid analgesics can cause tachycardia. 4. Around-the-clock dosing gives better pain relief than as- needed dosing. Answer: 4 Test-Taking Strategy: Focus on what the question is asking and consider the client’s diagnosis of terminal cancer. Around-the- clock dosing provides increased pain relief and decreases stressors associated with pain, such as anxiety and fear. Pain is what the client describes it as, and any indication of pain should be perceived as real for the client. Opioid analgesics may be addictive, but this is not a concern for a client with ter- minal cancer. Not all opioid analgesics cause tachycardia. Remember to focus on what the question is asking. 21 CHAPTER 4 Test-Taking Strategies
- 40. B. Some strategic words may indicate that all options are correct and that it will be necessary to prioritize to select the correct option; words that reflect the process of assessment are also important to note (see Box 4-4). Words that reflect assessment usually indicate the need to look for an option that is a first step, since assessment is the first step in the nursing process. C. As you read the question, look for the strategic words; strategic words make a difference regarding the focus of the question. Throughout this book, strategic words presented in the question, such as those that indicate the need to prioritize, are bolded. If the test-taking strategy is to focus on strategicwords, then strategic words is highlighted in blue where it appears in the test-taking strategy. IV. Subject of the Question (Box 4-6) A. The subject of the question is the specific topic that the question is asking about. B. Identifying the subject of the question will assist in eliminating the incorrect options and direct you in selecting the correct option. Throughout this book, if the subject of the question is a specific strategy to use in answering the question correctly, it is highlighted in blue in the test-taking strategy. Also, the specific content area to review, such as heart fail- ure, is bold in magenta where it appears in the test- taking strategy. C. The highlighting of the strategy and specific content areas will provide you with guidance on what strat- egies to review in Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam and the content areas in need of further remediation in Saunders Comprehensive Review for the NCLEX-RN® Examination. V. Positive and Negative Event Queries (Boxes 4-7 and 4-8) A. A positive event query uses strategic words that ask you to select an option that is correct; for example, the event query may read, “Which statement by a cli- ent indicates an understanding of the side effects of the prescribed medication?” B. A negative event query uses strategic words that ask you to select an option that is an incorrect item or statement; for example, the event query may read, N C L E X P r e p BOX 4-4 Common Strategic Words: Words That Indicate the Need to Prioritize and Words That Reflect Assessment Words That Indicate the Need to Prioritize Best Early or late Essential First Highest priority Immediate Initial Most Most appropriate Most important Most likely Next Primary Vital Words That Reflect Assessment Ascertain Assess Check Collect Determine Find out Gather Identify Monitor Observe Obtain information Recognize BOX 4-5 Practice Question: Strategic Words The nurse is caring for a client who just returned from the recoveryroom after undergoing abdominal surgery. The nurse should monitor for which early sign of hypovolemic shock? 1. Sleepiness 2. Increased pulse rate 3. Increased depth of respiration 4. Increased orientation to surroundings Answer: 2 Test-Taking Strategy: Note the strategic word, early, in the query and the word just in the event. Think about the patho- physiology that occurs in hypovolemic shock to direct you to the correct option. Restlessness is one of the earliest signs followed by cardiovascular changes (increased heart rate and a decrease in blood pressure). Sleepiness is expected in a cli- ent who has just returned from surgery. Although increased depth of respirations occurs in hypovolemic shock, it is not an early sign. Rather, it occurs as the shock progresses. This is why it is important to recognize the strategic word, early, when you read the question. It requires the ability to discern between early and late signs of impending shock. Increased orientation to surroundings is expected and will occur as the effects of anesthesia resolve. Remember to look for stra- tegic words, in both the event and the query of the question. BOX 4-6 Practice Question: Subject of the Question The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most helpful for this client? 1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials Answer: 3 Test-Taking Strategy: Focus on the subject, increasing bed mobility. Also note the strategic word, most. The use of an overhead trapeze is extremely helpful in assisting a client to move about in bed and to get on and off the bedpan. Televi- sion and reading materials are helpful in reducing boredom and providing distraction and a fracture bedpan is useful in reducing discomfort with elimination; these items are helpful for a client in traction, but they are not directly related to the subject of the question. Remember to focus on the subject. 22 UNIT I NCLEX-RN® Exam Preparation
- 41. “Which statement by a client indicates a need for fur- ther teaching about the side effects of the prescribed medication?” VI. Questions That Require Prioritizing A. Many questions in the examination will require you to use the skill of prioritizing nursing actions. B. Look for the strategic words in the question that indi- cate the need to prioritize (see Box 4-4). C. Remember that when a question requires prioritiza- tion, all options may be correct and you need to determine the correct order of action. D. Strategies to use to prioritize include the ABCs (air- way–breathing–circulation), Maslow’s Hierarchy of Needs theory, and the steps of the nursing process. E. The ABCs (Box 4-9) 1. Use the ABCs—airway–breathing–circulation— when selecting an answer or determining the order of priority. 2. Remember the order ofpriority:airway–breathing– circulation. 3. Airway is always the first priority. Note that an exception occurs when cardiopulmonary resusci- tation is performed;in this situation, the nurse fol- lows the CAB (compressions–airway–breathing) guidelines. F. Maslow’s Hierarchy of Needs theory (Box 4-10; Fig. 4-1) 1. According to Maslow’s Hierarchy of Needs the- ory, physiological needs are the priority, fol- lowed by safety and security needs, love and belonging needs, self-esteem needs, and, finally, self-actualization needs; select the option or determine the order of priority by addressing physiological needs first. N C L E X P r e p BOX4-7 Practice Question: Positive Event Query The nurse provides medication instructions to a client about digoxin. Which statement by the client indicates an under- standing of its adverse effects? 1. “Blurred vision is expected.” 2. “If I am nauseated or vomiting, I should stayon liquids and take some liquid antacids.” 3. “This medication may cause headache and weakness but that is nothing to worry about.” 4. “If my pulse rate drops below 60 beats per minute I should let my health care provider know.” Answer: 4 Test-Taking Strategy: This question is an example of a positive event queryquestion. Note the words indicatesan understanding, and focus on the subject, adverse effects. Additionally, focus on the data provided in the options. Digoxin is a cardiac glycoside and works byincreasing contractilityof the heart. This medica- tion has a narrow therapeutic range and a major concern is tox- icity. Currently, it is considered second-line treatment for heart failure because ofits narrowtherapeutic range and potential for adverse effects. Adverse effects that indicate toxicity include gastrointestinal disturbances, neurological abnormalities, bra- dycardia or other cardiac irregularities, and ocular disturbances. If anyof these occur, the health care provider (HCP) is notified. Additionally, the client should notify the HCP if the pulse rate drops below60 beats per minute because serious dysrhythmias are another potential adverse effect ofdigoxin therapy. Remem- ber to focus on the data provided and note positive event queries. BOX 4-8 Practice Question: Negative Event Query The nurse has reinforced discharge instructions to a client who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the client indicates a need for further teaching regarding home care measures? 1. “I should use a straight razor to shave under myarms.” 2. “I need to be sure that I do not have blood pressures or blood drawn from my right arm.” 3. “I should inform all of my other health care providers that I have had this surgical procedure.” 4. “I need to be sure to wear thick mitt hand covers or use thick pot holders when I am cooking and touching hot pans.” Answer: 1 Test-Taking Strategy: This question is an example ofa negative event query. Note the strategic words, need for further teaching. These strategic words indicate that you need to select an option that identifies an incorrect client statement. Recall that edema and infection are concerns with this client due to the removal of lymph nodes in the surgical area. Lymphadenopathycan result and the client needs to be instructed in the measures that will avoid trauma to the affected arm. Recalling that trauma to the affected arm could potentiallyresult in edema and/or infection will direct you to the correct option. Remember to watch for negative event queries. BOX 4-9 Practice Question: Use of the ABCs A client with a diagnosis of cancer is receiving morphine sul- fate for pain. The nurse should employwhich priorityaction in the care of the client? 1. Monitor stools. 2. Encourage fluid intake. 3. Monitor urine output. 4. Encourage the client to cough and deep breathe. Answer: 4 Test-Taking Strategy: Use the ABCs—airway–breathing– circulation—as a guide to direct you to the correct option and note the strategic word, priority. Recall that morphine sul- fate suppresses the cough reflexand the respiratoryreflex, and a common adverse effect is respiratorydepression. Coughing and deep breathing can assist with ensuring adequate oxygen- ation since the number of respirations per minute can poten- tially be decreased in a client receiving this medication. Although options 1, 2, and 3 are components of the plan of care, the correct option addresses airway. Remember to use the ABCs—airway–breathing–circulation—to prioritize. 23 CHAPTER 4 Test-Taking Strategies
- 42. 2. When a physiological need is not addressed in the question or noted in one of the options, con- tinue to use Maslow’s Hierarchy of Needs theory sequentially as a guide and look for the option that addresses safety. G. Steps of the nursing process 1. Use the steps of the nursing process to prioritize. 2. The steps include assessment, analysis, planning, implementation, and evaluation (AAPIE) and are followed in this order. 3. Assessment a. Assessment questions address the process of gathering subjective and objective data rela- tive to the client, confirming the data, and communicating and documenting the data. b. Remember that assessment is the first step in the nursing process. c. When you are asked to select your first, imme- diate, or initial nursing action, follow the steps of the nursing process to prioritize when selecting the correct option. d. Look for words in the options that reflect assessment (see Box 4-4). e. If an option contains the concept of assess- ment or the collection of client data, the best choice is to select that option (Box 4-11). f. If an assessment action is not one of the options, follow the steps ofthe nursingprocess as your guide to select your next best action. g. Possible exception to the guideline—if the question presents an emergency situation, read carefully; in an emergency situation, an intervention may be the priority rather than taking the time to assess further. N C L E X P r e p BOX4-10 Practice Question: Maslow’s Hierarchy of Needs Theory The nurse caring for a client experiencing dystocia determines that the priority is which action? 1. Position changes and providing comfort measures 2. Explanations to familymembers about what is happen- ing to the client 3. Monitoring for changes in the physical condition of the mother and fetus 4. Reinforcement of breathing techniques learned in child- birth preparatory classes Answer: 3 Test-Taking Strategy: All the options are correct and would be implemented during the care of this client. Note the strategic word, priority, and use Maslow’s Hierarchy of Needs theory to prioritize, remembering that physiological needs come first. Also, the correct option is the only one that addresses both the mother and the fetus. Remember to use Maslow’s Hierar- chy of Needs theory to prioritize. Nurs ing Priorities from Mas low's Hierarchy of Needs Theory Self- Actualization Hope Spiritual well-being Enhanced growth Self-Es teem Control Competence Positive regard Acceptance/worthiness Love and Belonging Maintain support systems Protect from isolation Safety and Security Protection from injury Promote feeling of security Trust in nurse-client relationship Bas ic Phys iological Needs Airway Respiratory effort Heart rate, rhythm, and strength of contraction Nutrition Elimination FIGURE4-1 Use Maslow’s HierarchyofNeeds theoryto establish priorities. BOX 4-11 Practice Question: The Nursing Process—Assessment Aclient who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first? 1. Elevate the arm. 2. Document the findings. 3. Medicate with an additional dose of an opioid. 4. Check for paresthesias and paralysis of the right arm. Answer: 4 Test-Taking Strategy: Note the strategic word, first. Based on the data in the question, determine if an abnormality exists. The question event indicates that the client complains of pain at the wrist when the arm is passivelymoved. This could indi- cate an abnormality; therefore, further assessment or inter- vention is required. Use the steps of the nursing process, remembering that assessment is the first step. The only option that addresses assessment is the correct option. Options 1, 2, and 3 address the implementation step of the nursing process. Also, these options are inaccurate first actions. The arm in a cast should have already been elevated. The client may be experiencing compartment syndrome, a complication following trauma to the extremities and applica- tion of a cast. Additional data need to be collected to deter- mine whether this complication is present. Remember that assessment is the first step in the nursing process. 24 UNIT I NCLEX-RN® Exam Preparation
- 43. 4. Analysis (Box 4-12) a. Analysis questions are the most difficult ques- tions because they require understanding of the principles of physiological responses and require interpretation of the assessment data. b. Analysis questions require critical thinking and determining the rationale for therapeutic prescriptions or interventions that may be addressed in the question. c. Analysisquestionsmayaddressthe formulation of a statement that identifies a client need or problem. Analysis questions may also include the communication and documentation of the results from the process of the analysis. d. Often, these types of questions require assim- ilation of more than one piece of information and application to a client scenario. 5. Planning (Box 4-13) a. Planning questions require prioritizing client problems, determining goals and outcome criteria for goals of care, developing the plan of care, and communicating and document- ing the plan of care. b. Remember that actual client problems rather than potential client problems will most likely be the priority. 6. Implementation (Box 4-14) a. Implementation questions address the pro- cess of organizing and managing care, counseling and teaching, providing care to achieve established goals, supervising and coordinating care, and communicating and documenting nursing interventions. b. Focus on a nursing action rather than on a medical action when you are answering a question, unless the question is asking you what prescribed medical action is anticipated. N C L E X P r e p BOX 4-12 Practice Question: The Nursing Process—Analysis The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 30 mm Hg, and HCO3 22 mEq/L (22 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated Answer: 2 Test-Taking Strategy: Use the steps of the nursing process and analyze the values. The question does not require further assessment; therefore, it is appropriate to move to the next step in the nursing process, analysis. The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. So, you can eliminate options 1and 3. In an alkalytic condition, the pH is elevated. The values identified indicate a respiratory alkalosis. Compensation occurs when the pH returns to a nor- mal value. Because the pH is in the normal range at the high end, compensation has occurred. Remember that analysis is the second step in the nursing process. BOX 4-13 Practice Question: The Nursing Process—Planning The nurse developing a plan of care for a client with a cataract understands that which problem is the priority? 1. Concern about the loss of eyesight 2. Altered vision due to opacity of the ocular lens 3. Difficultymoving around because ofthe need for glasses 4. Becoming lonely because of decreased community immersion Answer: 2 Test-Taking Strategy: Note the strategic word, priority, and use the steps of the nursing process. This question relates to plan- ning nursing care and asks you to identifythe priorityproblem. Use Maslow’s Hierarchy of Needs theory to answer the ques- tion, remembering that physiological needs are the priority. Concern and becoming lonely are psychosocial needs and would be the last priorities. Note that the correct option directly addresses the client’s problem. Remember that plan- ning is the third step of the nursing process. BOX 4-14 Practice Question: The Nursing Process—Implementation The nurse is caring for a hospitalized client with angina pec- toris who begins to experience chest pain. The nurse admin- isters a nitroglycerin tablet sublinguallyas prescribed, but the pain is unrelieved. The nurse should take which action next? 1. Reposition the client. 2. Call the client’s family. 3. Contact the health care provider. 4. Administer another nitroglycerin tablet. Answer: 4 Test-Taking Strategy: Note the strategic word, next, and use the steps of the nursing process. Implementation questions address the process of organizing and managing care. This question also requires that you prioritize nursing actions. Additionally, focus on the data in the question to assist in avoiding reading into the question. You may think it is neces- saryto check the blood pressure before administering another tablet, which is correct. However, there are no data in the question indicating that the blood pressure is abnormal and could not sustain normality if another tablet were given. In addition, checking the blood pressure is not one of the options. Recalling that the nurse would administer 3nitroglyc- erin tablets 5 minutes apart from each other to relieve chest pain in a hospitalized client will assist in directing you to the correct option. Remember that implementation is the fourth step of the nursing process. 25 CHAPTER 4 Test-Taking Strategies
- 44. c. On the NCLEX-RN exam, the only client that you need to be concerned about is the client in the question that you are answering; avoid the “What if …?” syndrome and remember that the client in the question on the com- puter screen is your only assigned client. d. Answer the question from a textbook and ideal point of view; remember that the nurse has all of the time and all of the equipment needed to care for the client readily available at the bedside; remember that you do not need to run to the supply room to obtain, for example, sterile gloves because the sterile gloves will be at the client’s bedside. 7. Evaluation (Box 4-15) a. Evaluation questions focus on comparing the actual outcomes of care with the expected outcomes and on communicating and docu- menting findings. b. These questions focus on assisting in deter- mining the client’s response to care and iden- tifying factors that may interfere with achieving expected outcomes. c. In an evaluation question, watch for negative event queries because they are frequently used in evaluation-type questions. H. Determine if an Abnormality Exists (Box 4-16) 1. In the event, the client scenario will be described. Use your nursing knowledge to determine if any of the information presented is indicating an abnormality. 2. If an abnormality exists, either further assess- ment or further intervention will be required. Therefore, continuing to monitor or document- ing will not be a correct answer; don’t select these options if they are presented! VII. Client Needs A. Safe and Effective Care Environment 1. According to the National Council of State Boards of Nursing (NCSBN), these questions test the concepts of providing safe nursing care and collaborating with other health care team mem- bers to facilitate effective client care; these ques- tions also focus on the protection of clients, significant others, and health care personnel from environmental hazards. 2. Focus on safety with these types of questions, and remember the importance of hand washing, call lights or bells, bed positioning, appropriate use of side rails, asepsis, use of standard and other precautions, triage, and emergency response planning. N C L E X P r e p BOX 4-15 Practice Question: The Nursing Process—Evaluation The nurse is evaluating the client’s response to treatment of a pleural effusion with a chest tube. The nurse notes a respira- toryrate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 mL since the previous shift. Based on this information, which interpretation should the nurse make? 1. The client is responding well to treatment. 2. Suction should be decreased to the system. 3. The system should be assessed for an air leak. 4. Water should be added to the water seal chamber. Answer: 1 Test-Taking Strategy: Use the steps of the nursing process and note that the nurse needs to evaluate the client’s response to treatment. Focus on the subject and the data in the ques- tion. Also, determine if an abnormality exists based on these data. Remember that fluctuation in the water sealchamber is a normal and expected finding with a chest tube. Since the client is being treated for a pleural effusion, it can be determined that he or she is responding well to treatment if the amount of drainage is gradually decreasing because the fluid from the pleural effusion is being effectively removed. If the drain- age were to stop suddenly, the chest tube should be assessed for a kink or blockage. There is no indication based on the data in the question to decrease suction to the system; in fact, it is unclear as to whether the client is on suction at all. There are also no data in the question indicating an air leak. Lastly, there are no data in the question indicating the need to add water to the water seal chamber; again, it is unclear as to whether the client has this type of chest tube versus a dry suction chest tube. Remember that evaluation is the fifth step ofthe nursing process. BOX 4-16 Practice Question: Determine If an Abnormality Exists The nurse is caring for a client being admitted to the emer- gencydepartment with a chief complaint of anorexia, nausea, and vomiting. The nurse asks the client about the home med- ications being taking. The nurse would be most concerned if the client stated that which medication was being taken at home? 1. Digoxin 2. Captopril 3. Losartan 4. Furosemide Answer: 1 Test-Taking Strategy: Note the strategic word, most. The first step in approaching the answer to this question is to deter- mine if an abnormality exists. The client is complaining of anorexia, nausea, and vomiting; therefore, an abnormality does exist. This tells you that this could be an adverse or toxic effect of one of the medications listed. Although gastrointes- tinal distress can occur as an expected side effect of many medications, anorexia, nausea, and vomiting are hallmark signs of digoxin toxicity. Therefore, the nurse would be most concerned with this medication if taken at home bythe client. Remember to first determine if an abnormality exists in the event before choosing the correct option. 26 UNIT I NCLEX-RN® Exam Preparation
- 45. B. Physiological Integrity 1. The NCSBN indicates that these questions test the concepts that the nurse provides care as it relates to comfort and assistance in the perfor- mance of activities of daily living as well as care related to the administration of medications and parenteral therapies. 2. These questions also address the nurse’s ability to reduce the client’s potential for developing com- plications or health problems related to treat- ments, procedures, or existing conditions and to provide care to clients with acute, chronic, or life-threatening physical health conditions. 3. Focus on Maslow’s Hierarchy of Needs theory in these types of questions and remember that physiological needs are a priority and are addressed first. 4. Use the ABCs—airway–breathing–circulation— and the steps of the nursing process when select- ing an option addressing Physiological Integrity. C. Psychosocial Integrity 1. The NCSBN notes that these questions test the concepts of nursing care that promote and sup- port the emotional, mental, and social well- being of the client and significant others. 2. Content addressed in these questions relates to supporting and promoting the client’s or signifi- cant others’abilityto cope, adapt, or problem-solve in situations such as illnesses; disabilities; or stress- ful events including abuse, neglect, or violence. 3. In this Client Needs category, you may be asked communication-type questions that relate to how you would respond to a client, a client’s family member or significant other, or other health care team members. 4. Use therapeutic communication techniques to answer communication questions because oftheir effectiveness in the communication process. 5. Remember to select the option that focuses on the thoughts, feelings, concerns, anxieties, or fears of the client, client’s family member, or sig- nificant other (Box 4-17). D. Health Promotion and Maintenance 1. According to the NCSBN, these questions test the concepts that the nurse provides and assists in directing nursing care to promote and maintain health. 2. Content addressed in these questions relates to assisting the client and significant others during the normal expected stages of growth and devel- opment, and providing client care related to the prevention and early detection of health problems. 3. Use the Teaching and Learning theory if the ques- tion addresses client teaching, remembering that the client’s willingness, desire, and readiness to learn is the first priority. 4. Watch for negative event queries because they are frequently used in questions that address Health Promotion and Maintenance and client education. VIII. Eliminate Comparable or Alike Options (Box 4-18) A. When reading the options in multiple-choice or multiple-response questions, look for options that are comparable or alike. B. Comparable or alike options can be eliminated as possible answers because it is not likely for both options to be correct. N C L E X P r e p BOX 4-17 Practice Question: Communication Aclient scheduled for bowel surgery states to the nurse, “I’m not sure if I should have this surgery.” Which response bythe nurse is appropriate? 1. “It’s your decision.” 2. “Don’t worry. Everything will be fine.” 3. “Why don’t you want to have this surgery?” 4. “Tell me what concerns you have about the surgery.” Answer: 4 Test-Taking Strategy: Use therapeutic communication tech- niques to answer communication questions and remember to focus on the client’s thoughts, feelings, concerns, anxieties, and fears. The correct option is the onlyone that addresses the client’s concern. Additionally, asking the client about what specific concerns he or she has about the surgery will allow for further decisions in the treatment process to be made. Option 1is a blunt response and does not address the client’s concern. Option 2 provides false reassurance. Option 3 can make the client feel defensive and uses the nontherapeutic communication technique of asking “why.” Remember to use therapeutic communication techniques and focus on the client. BOX 4-18 Practice Question: Eliminate Comparable or Alike Options The nurse is caring for a group of clients. On review of the cli- ents’ medical records, the nurse determines that which client is at risk for excess fluid volume? 1. The client taking diuretics 2. The client with an ileostomy 3. The client with kidney disease 4. The client undergoing gastrointestinal suctioning Answer: 3 Test-Taking Strategy: Focus on the subject, the client at risk for excess fluid volume. Think about the pathophysiology associated with each condition identified in the options. The only client who retains fluid is the client with kidney dis- ease. The client taking diuretics, the client with an ileostomy, and the client undergoing gastrointestinal suctioning all lose fluid; these are comparable or alike options. Remember to eliminate comparable or alike options. 27 CHAPTER 4 Test-Taking Strategies
- 46. IX. Eliminate Options Containing Closed-Ended Words (Box 4-19) A. Some closed-ended words are all, always, every, must, none, never, and only. B. Eliminate options that contain closed-ended words because these words imply a fixed or extreme mean- ing; these types of options are usually incorrect. C. Options that contain open-ended words, such as may, usually, normally, commonly, or generally, should be considered as possible correct options. X. Look for the Umbrella Option (Box 4-20) A. When answering a question, look for the umbrella option. B. The umbrella option is one that is a broad or univer- sal statement and that usually contains the concepts of the other options within it. C. The umbrella option will be the correct answer. XI. Use the Guidelines for Delegating and Assignment Making (Box 4-21) A. You may be asked a question that will require you to decide how you will delegate a task or assign clients to other health care providers (HCPs). B. Focus on the information in the question and what task or assignment is to be delegated. C. When you have determined what task or assignment is to be delegated, consider the client’s needs and match the client’s needs with the scope of practice of the HCPs identified in the question. D. The Nurse Practice Act and any practice limitations define which aspects of care can be delegated and which must be performed by a registered nurse. Use nursing scope of practice as a guide to assist in answering questions. Remember that the NCLEX is a national exam and national standards rather than agency-specific standards must be followed when delegating. E. In general, noninvasive interventions, such as skin care, range-of-motion exercises, ambulation, groom- ing, and hygiene measures, can be assigned to an unlicensed assistive personnel (UAP). F. A licensed practical nurse (LPN) can perform the tasks that a UAP can perform and can usually per- form certain invasive tasks, such as dressings, suc- tioning, urinary catheterization, and administering medications orally or by the subcutaneous or N C L E X P r e p BOX 4-19 Practice Question: Eliminate Options That Contain Closed-Ended Words A client is to undergo a computed tomography (CT) scan of the abdomen with oral contrast, and the nurse provides pre- procedure instructions. The nurse instructs the client to take which action in the preprocedure period? 1. Avoid eating or drinking after midnight before the test. 2. Limit selfto only2 cigarettes on the morning ofthe test. 3. Have a clear liquid breakfast onlyon the morning of the test. 4. Take all routine medications with a glass ofwater on the morning of the test. Answer: 1 Test-Taking Strategy: Note the closed-ended words only in options 2 and 3and all in option 4. Eliminate options that con- tain closed-ended words because these options are usually incorrect. Also, note that options 2, 3, and 4 are comparable or alike options in that they all involve taking in something on the morning of the test. Remember to eliminate options that contain closed-ended words. BOX 4-20 Practice Question: Look for the Umbrella Option A client admitted to the hospital is diagnosed with urethritis caused by chlamydial infection. The nurse should implement which precaution to prevent contraction of the infection dur- ing care? 1. Enteric precautions 2. Contact precautions 3. Standard precautions 4. Wearing gloves and a mask Answer: 3 Test-Taking Strategy: Focus on the client’s diagnosis and recall that this infection is sexuallytransmitted. Also, note that the correct option is the umbrella option. Remember to look for the umbrella option, a broad or universal option that includes the concepts of the other options in it. BOX 4-21 Practice Question: Use Guidelines for Delegating and Assignment Making The nurse in charge of a long-term care facilityis planning the client assignments for the day. Which client should be assigned to the unlicensed assistive personnel (UAP)? 1. A client on strict bed rest 2. A client with dyspnea who is receiving oxygen therapy 3. Aclient scheduled for transfer to the hospital for surgery 4. Aclient with a gastrostomytube who requires tube feed- ings every 4 hours Answer: 1 Test-Taking Strategy: Note the subject of the question, the assignment to be delegated to the UAP. When asked ques- tions about delegation, think about the role description and scope of practice of the employee and the needs of the client. Aclient with dyspnea who is receiving oxygen therapy, a client scheduled for transfer to the hospital for surgery, or a client with a gastrostomy tube who requires tube feedings every 4 hours has both physiological and psychosocial needs that require care by a licensed nurse. The UAP has been trained to care for a client on bed rest. Remember to match the client’s needs with the scope of practice of the health care provider. 28 UNIT I NCLEX-RN® Exam Preparation
- 47. intramuscular route; some selected piggyback intra- venous medications may also be administered. G. Aregistered nurse can perform the tasks that an LPN can perform and is responsible for assessment and planning care, analyzing client data, implement- ing and evaluating client care, supervising care, initi- ating teaching, and administering medications intravenously. XII. Answering Pharmacology Questions (Box 4-22) A. If you are familiar with the medication, use nursing knowledge to answer the question. B. Remember that the question will identify the generic name of the medication on most occasions. C. If the question identifies a medical diagnosis, try to form a relationship between the medication and the diagnosis; for example, you can determine that cyclophosphamide is an antineoplastic medication if the question refers to a client with breast cancer who is taking this medication. D. Try to determine the classification of the medication being addressed to assist in answering the question. Identifying the classification will assist in determin- ing a medication’s action or side effects or both. E. Recognize the common side effects and adverse effects associated with each medication classification and relate the appropriate nursing interventions to each effect; for example, if a side effect is hyperten- sion, the associated nursing intervention would be to monitor the blood pressure. F. Focus on what the question is asking or the subject of the question; for example: intended effect, side effect, adverse effect, or toxic effect. G. Learn medications that belong to a classification by commonalities in their medication names; for example, medications that act as beta blockers end with “-lol” (e.g., atenolol). H. If the question requires a medication calculation, remember that a calculator is available on the com- puter; talk yourself through each step to be sure the answer makes sense, and recheck the calculation before answering the question, particularly if the answer seems like an unusual dosage. I. Pharmacology: Pyramid Points to remember 1. In general, the client should not take an antacid with medication because the antacid will affect the absorption of the medication. 2. Enteric-coated and sustained-release tablets should not be crushed; also, capsules should not be opened. 3. The client should never adjust or change a med- ication dose or abruptly stop taking a medication. 4. The nurse never adjusts or changes the client’s medication dosage and never discontinues a medication. 5. The client needs to avoid taking any over-the- counter medications or any other medications, such as herbal preparations, unless they are approved for use by the HCP. 6. The client needs to avoid consuming alcohol. 7. Medications are never administered if the prescription is difficult to read, is unclear, or identifies a medication dose that is not a normal one. 8. Additional strategies for answering pharmacol- ogy questions are presented in Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam. N C L E X P r e p BOX 4-22 Practice Question: Answering Pharmacology Questions Quinapril hydrochloride is prescribed as adjunctive therapyin the treatment of heart failure. After administering the first dose, the nurse should monitor which item as the priority? 1. Weight 2. Urine output 3. Lung sounds 4. Blood pressure Answer: 4 Test-Taking Strategy: Focus on the name of the medication and note the strategic word, priority. Recall that the medica- tion names of most angiotensin-converting enzyme (ACE) inhibitors end with “-pril” and one of the indications for use of these medications is hypertension. Excessive hypotension (“first-dose syncope”) can occur in clients with heart failure or in clients who are severely sodium-depleted or volume- depleted. Although weight, urine output, and lung sounds would be monitored, monitoring the blood pressure is the pri- ority. Remember to use pharmacology guidelines to assist in answering questions about medications and note the strate- gic words. 29 CHAPTER 4 Test-Taking Strategies
- 48. UNIT II Professional Standards in Nursing Pyramid to Success Nurses often care for clients who come from ethnic, cul- tural, or religious backgrounds that are different from their own. In the past 10 years, the Hispanic population in the United States has increased by 43%, the African American population by 12.3%, and the Asian popula- tion by 43% (U.S. Census Bureau, 2010). It is projected that minority groups will make up a majority of the U.S. population by 2042 (U.S. Department of State, 2008). Awareness of and sensitivity to the unique health and illness beliefs and practices of people of different backgrounds are essential for the delivery of safe and effective care. Acknowledgment and acceptance of cul- tural differences with a nonjudgmental attitude are essential to providing culturally sensitive care. The NCLEX-RN® exam test plan is unique and individual- ized to the client’s culture and beliefs. The nurse needs to avoid stereotyping and needs to be aware that there are several subcultures within cultures and there are sev- eral dialects within languages. In nursing practice, the nurse should assess the client’s perceived needs before planning and implementing a plan of care. Across all settings in the practice of nursing, nurses fre- quently are confronted with ethical and legal issues related to client care. The professional nurse has the responsibility to be aware of the ethical principles, laws, and guidelines related to providing safe and quality care to clients. In the Pyramid to Success, focus on ethical prac- tices; the Nurse Practice Act and clients’rights, particularly confidentiality, information security and confidentiality, and informed consent; advocacy, documentation, and advance directives; and cultural, religious, and spiritual issues. Knowledgeable use of information technology, such as an electronic health record, is also an important role of the nurse. The National Council of State Boards of Nursing (NCSBN) defines management of care as the nurse directing nursing care to enhance the care delivery set- ting to protect the client and health care personnel. As described in the NCLEX-RN exam test plan, a profes- sional nurse needs to provide integrated, cost-effective care to clients by coordinating, supervising, and collab- orating or consulting with members of the interprofes- sional health care team. A primary Pyramid Point focuses on the skills required to prioritize client care activities. Pyramid Points also focus on concepts of lead- ership and management, the process of delegation, emergency response planning, and triaging clients. Client Needs: Learning Objectives Safe and Effective Care Environment Acting as a client advocate Integrating advance directives into the plan of care Becoming familiar with the emergency response plan Delegating client care activities and providing continuity of care Ensuring that ethical practices are implemented Ensuring that informed consent has been obtained Ensuring that legal rights and responsibilities are maintained Collaborating with interprofessional teams Establishing priorities related to client care activities Instituting quality improvement procedures Integrating case management concepts Maintaining confidentiality and information security issues related to the client’s health care Supervising the delivery of client care Triaging clients Upholding client rights Using information technology in a confidential manner Using leadership and management skills effectively F u n d a m e n t a l s 30
- 49. Health Promotion and Maintenance Considering cultural and spiritual issues related to fam- ily systems and family planning Identifying changes related to the aging process Identifying high-risk behaviors of the client Performing physical assessment techniques Promoting health and preventing disease Promoting the client’s ability to perform self-care Providing health screening and health promotion programs Respecting cultural preferences and lifestyle choices Psychosocial Integrity Addressing end-of-life care based on the client’s prefer- ences and beliefs Assessing the use of effective coping mechanisms Becoming aware of cultural and spiritual preferences and incorporating these preferences when planning and implementing care Identifying abuse and neglect issues Identifying clients who do not speak or understand English and determining how language needs will be met by the use of agency-approved interpreters Identifying end-of-life care issues Identifying family dynamics as they relate to the client’s culture Identifying support systems for the client Providing a therapeutic environment and building a relationship based on trust Respecting religious and spiritual influences on health (see Box 5-1) Physiological Integrity Ensuring that emergencies are handled using a prioriti- zation procedure Identifying cultural and spiritual differences for provid- ing holistic client care Identifying cultural issues related to alternative and com- plementary therapies Identifying cultural issues related to receiving blood and blood products Implementing therapeutic procedures considering cul- tural preferences Providing nonpharmacological comfort interventions Providing nutrition and oral hydration, considering cul- tural preferences (see Box 5-1) Ensuring that palliative and comfort care is provided to the client Monitoring for alterations in body systems or unex- pected responses to therapy 31 UNIT II Professional Standards in Nursing F u n d a m e n t a l s
- 50. F u n d a m e n t a l s CH AP TER 5 Cultural Awareness and Health Practices PRIORITYCONCEPTS Culture; Health Promotion CRITICALTHINK ING W hat Should Y ou Do? The nurse is preparing a client for an echocardiogram and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to removing this personal item from the client? Answer located on p. 40. For reference throughout the chapter, see Figure 5-1 and Box 5-1. Cultural awareness includes learning about the cultures of clients with whom you will be working; also, ask clients about their health care practices and preferences. I. African Americans A. Description: Citizens or residents of the United States who may have origins in any of the black populations in Africa. B. Communication 1. Members are competent in standard English. 2. Head nodding does not always mean agreement. 3. Prolonged eye contact may be interpreted as rudeness or aggressive behavior. 4. Nonverbal communication may be important. 5. Personal questions asked on initial contact with a person may be viewed as intrusive. C. Time orientation and personal space preferences 1. Time orientation varies according to age, socio- economics, and subcultures and may include past, present, or future orientation. 2. Members may be late for an appointment because relationships and events that are occur- ring may be deemed more important than being on time. 3. Members are comfortable with close personal space when interacting with family and friends. D. Social roles 1. Large extended-family networks are important; older adults are respected. 2. Many households may be headed by a single- parent woman. 3. Religious beliefs and church affiliation are sources of strength. E. Health and illness 1. Religious beliefs profoundly affect ideas about health and illness. 2. Food preferences include such items as fried foods, chicken, pork, greens such as collard greens, and rice; some pregnant African American women engage in pica. F. Health risks 1. Sickle cell anemia 2. Hypertension 3. Heart disease 4. Cancer 5. Lactose intolerance 6. Diabetes mellitus 7. Obesity G. Interventions 1. Assess the meaning of the client’s verbal and nonverbal behavior. 2. Be flexible and avoid rigidity in scheduling care. 3. Encourage family involvement. 4. Alternative modes of healing include herbs, prayer, and laying on of hands practices. Assess each individual for cultural preferences because there are many individual and subculture variations. II. Amish A. Description 1. The Amish are known for simple living, plain dress, and reluctance to adopt modern conve- nience and can be considered a distinct ethnic group ; the various Amish church fellowships are Christian religious denominations that form a very traditional subgrouping of Mennonite churches. 2. Cultural beliefs and preferences vary depending on specific Amish community membership. 32
- 51. F u n d a m e n t a l s • Summarize data obtained Nurs ing as s es s ment • Client's cultural and racial identification • Place of birth • Time in country Culturally unique individual • Language spoken • Voice quality • Pronunciation • Use of silence • Use of nonverbals Communication • Degree of comfort observed (conversation) • Proximity to others • Body movement • Perception of space Space • Culture • Race • Ethnicity • Family Role Function Social orientation • Work • Leisure • Church • Friends • Use of • Measures • Definition • Social time • Work time • Time orientation Future Present Past Time • Cultural health practices Efficacious Neutral Dysfunctional Uncertain • Values • Definition of health and illness Environmental control • Body structure • Skin color • Hair color • Other physical dimensions • Enzymatic and genetic existence of diseases specific to populations • Susceptibility to illness and disease • Nutritional preferences and deficiencies • Psychological characteristics, coping, and social support Biological variations FIGURE 5-1 Giger and Davidhizar’s Transcultural Assessment Model. BOX 5-1 Religions and Dietary Preferences Buddhism Alcohol is usually prohibited. Many are lacto-ovo vegetarians. Some eat fish, and some avoid only beef. Church of Jesus Christ of Latter-day Saints (Mormon) Alcohol, coffee, and tea are usually prohibited. Consumption of meat is limited. The first Sunday of the month is optional for fasting. Eastern Orthodox During Lent, all animal products, including dairy products, are forbidden. Fasting occurs during Advent. Exceptions from fasting include illness and pregnancy; children may also be exempt. Hinduism Manyare vegetarians;those who eat meat do not eat beefor pork. Fasting rituals vary. Children are not allowed to participate in fasting. Islam Pork, birds of prey, alcohol, and any meat product not ritually slaughtered are prohibited. During the month of Ramadan, fasting occurs during the day- time; some individuals, such as pregnant women, may be exempt from fasting. Jehovah’s Witnesses Any foods to which blood has been added are prohibited. They can eat animal flesh that has been drained. Judaism Orthodox believers need to adhere to dietary kosher laws: ▪ Meats allowed include animals that are vegetable eaters, cloven-hoofed animals (deer, cattle, goats, sheep), and animals that are ritually slaughtered. ▪ Fish that have scales and fins are allowed. ▪ Anycombination of meat and milk is prohibited; fish and milk are not eaten together. During Yom Kippur, 24-hour fasting is observed. Pregnant women, children, and ill individuals are exempt from fasting. During Passover, only unleavened bread is eaten. Pentecostal (Assembly of God) Alcohol is usually prohibited. Members avoid consumption of anything to which blood has been added. Some individuals avoid pork. Roman Catholicism They avoid meat on Ash Wednesday and Fridays of Lent. They practice optional fasting during Lent season. Children, pregnant women, and ill individuals are exempt from fasting. Seventh-Day Adventist (Church of God) Alcohol and caffeinated beverages are usually prohibited. Manyare lacto-ovo vegetarians; those who eat meat avoid pork. Overeating is prohibited; 5 to 6 hours between meals without snacking is practiced. 33 CHAPTER 5 Cultural Awareness and Health Practices
- 52. F u n d a m e n t a l s 3. In general, they have fewer risk factors for disease than the general population because of their practice of manual labor, diet, and rare use of tobacco and alcohol; risk of certain genetic dis- orders is increased because of intermarriage (sexual abuse of women is a problem in some communities). 4. Diabetes mellitus can become a health issue later in life and is related to the obesity that can occur. B. Communication: Usually speak a German dialect called Pennsylvania Dutch; German language is usu- ally used during worship and English is usually learned in school. C. Time orientation and personal space preferences 1. Members generally remain separate from other communities, physically and socially. 2. They often work as farmers, builders, quilters, and homemakers. D. Social roles 1. Women are not allowed to hold positions of power in the congregational organization. 2. Roles of women are considered equally impor- tant to those of men but are very unequal in terms of authority. 3. Family life has a patriarchal structure. 4. Marriage outside the faith is not usually allowed; unmarried women remain under the authority of their fathers. E. Health and illness 1. Most Amish need to have church (bishop and community) permission to be hospitalized because the community will come together to help pay the costs. 2. Usually, Amish do not have health insurance because it is a “worldly product” and may show a lack of faith in God. 3. Some ofthe barriersto modern health care include distance, lack oftransportation, cost, and language (most do not understand scientific jargon). F. Health risks 1. Genetic disorders because of intermarriage (inbreeding) 2. Nonimmunization 3. Sexual abuse of women G. Interventions 1. Speak to both the husband and the wife or the unmarried woman and her father regarding health care decisions. 2. Health instructions must be given in simple, clear language. 3. Teaching should be focused on health implica- tions associated with nonimmunization, inter- marriage, and sexual abuse issues. Be alert to cues regarding eye contact, personal space, time concepts, and understanding of the recom- mended plan of care. III. Asian Americans A. Description: Americans of Asian descent; can include ethnic groups such as Chinese Americans, Filipino Americans, Indian Americans, Vietnamese Ameri- cans, Korean Americans, Japanese Americans, and others whose national origin is the Asian continent. B. Communication 1. Languages include Chinese, Japanese, Korean, Filipino, Vietnamese, and English. 2. Silence is valued. 3. Eye contact may be considered inappropriate or disrespectful (some Asian cultures interpret direct eye contact as a sexual invitation). 4. Criticism or disagreement is not expressed verbally. 5. Head nodding does not always mean agreement. 6. The word “no” may be interpreted as disrespect for others. C. Time orientation and personal space preferences 1. Time orientation reflects respect for the past, but includes emphasis on the present and future. 2. Formal personal space is preferred, except with family and close friends. 3. Members usually do not touch others during conversation. 4. For some cultures , touching is unacceptable between members of the opposite sex. 5. The head is considered to be sacred in some cultures; touching someone on the head may be disrespectful. D. Social roles 1. Members are devoted to tradition. 2. Large extended-family networks are common. 3. Loyalty to immediate and extended family and honor are valued. 4. The family unit is structured and hierarchical. 5. Men have the power and authority, and women are expected to be obedient. 6. Education is viewed as important. 7. Religions include Taoism, Buddhism, Confu- cianism, Shintoism, Hinduism, Islam, and Christianity. 8. Social organizations are strong within the community. E. Health and illness 1. Health is a state of physical and spiritual har- mony with nature and a balance between posi- tive and negative energy forces (yin and yang). 2. A healthy body may be viewed as a gift from the ancestors. 3. Illness may be viewed as an imbalance between yin and yang. 4. Illness may also be attributed to prolonged sit- ting or lying or to overexertion. 5. Food preferences include raw fish, rice, and vegetables. 34 UNIT II Professional Standards in Nursing
- 53. F u n d a m e n t a l s Yin foods are cold and yang foods are hot; one eats cold foods when one has a hot illness, and one eats hot foods when one has a cold illness. F. Health risks 1. Hypertension 2. Heart disease 3. Cancer 4. Lactose intolerance 5. Thalassemia G. Interventions 1. Be aware of and respect physical boundaries; request permission to touch the client before doing so. 2. Limit eye contact. 3. Avoid gesturing with hands. 4. A female client usually prefers a female health care provider (HCP). 5. Clarify responses to questions and expectations of the HCP. 6. Be flexible and avoid rigidity in scheduling care. 7. Encourage family involvement. 8. Alternative modes of healing include herbs, acu- puncture, restoration of balance with foods, mas- sage, and offering of prayers and incense. If health care recommendations, interventions, or treatments do not fit within the client’s cultural values, they will not be followed. IV. Hispanic and Latino Americans A. Description: Americans of origins in Latin countries; Mexican Americans, Cuban Americans, Colombian Americans,Dominican Americans,Puerto Rican Amer- icans, Spanish Americans, and Salvadoran Americans are some Hispanic and Latino American subgroups. B. Communication 1. Languages include primarily English and Spanish. 2. Members tend to be verbally expressive, yet con- fidentiality is important. 3. Avoiding eye contact with a person in authority may indicate respect and attentiveness. 4. Direct confrontation is usually disrespectful and the expression of negative feelings may be impolite. 5. Dramatic body language, such as gestures or facial expressions, may be used to express emo- tion or pain. C. Time orientation and personal space preferences 1. Members are usually oriented more to the present. 2. Members may be late for an appointment because relationships and events that are occur- ring are valued more than being on time. 3. Members are comfortable in close proximity with family, friends, and acquaintances. 4. Members are very tactile and use embraces and handshakes. 5. Members value the physical presence of others. 6. Politeness and modesty are important. D. Social roles 1. The nuclear family is the basic unit; also, large extended-family networks are common. 2. The extended family is highly regarded. 3. Needs of the family take precedence over the needs of an individual family member. 4. Depending on age and acculturation factors, men are usually the decision makers and wage earners, and women are the caretakers and homemakers. 5. Religion is usually Catholicism, but may vary depending on origin. 6. Members usually have strong church affiliations. 7. Social organizations are strong within the community. E. Health and illness 1. Health may be viewed as a reward from God or a result of good luck. 2. Some members believe that health results from a state of physical and emotional balance. 3. Illness may be viewed by some members to be a result of God’s punishment for sins. 4. Some members may adhere to nontraditional health measures such as folk medicine. 5. Food preferences include beans, fried foods, and spicy foods. F. Health risks 1. Hypertension 2. Heart disease 3. Diabetes mellitus 4. Obesity 5. Lactose intolerance 6. Parasites G. Interventions 1. Allow time for the client to discuss treatment options with family members. 2. Protect privacy. 3. Offer to call clergy because of the significance of religious preferences related to illnesses. 4. Ask permission before touching a child when planning to examine or care for him or her; some believe that touching the child is important when speaking to the child to prevent “evil-eye.” 5. Be flexible regarding time of arrival for appoint- ments and avoid rigidity in scheduling care. 6. Alternativemodesofhealingincludeherbs,consul- tation with lay healers, restoration of balance with hot or cold foods, prayer, and religious medals. Treat each client and individuals accompanying the client with respect and be aware of the differences and diversity of beliefs about health, illness, and treatment modalities. 35 CHAPTER 5 Cultural Awareness and Health Practices
- 54. F u n d a m e n t a l s V. Native Americans A. Description: Term that the U.S. government uses to describe indigenous peoples from the regions of North America encompassed by the continental United States, including parts of Alaska, and the island state of Hawaii; comprises a large number of distinct tribes, states, and ethnic groups, many of which survive as intact political communities. B. Communication 1. There is much linguistic diversity, depending on origin. 2. Use of a professional interpreter is important because of privacy concerns and because accu- racy of communication is made clearer. 3. Silence indicates respect for the speaker for some groups. 4. Some members may speak in a low tone of voice and expect others to be attentive. 5. Eye contact may be viewed as a sign of disrespect. 6. Body language is important. C. Time orientation and personal space preferences 1. Members are oriented primarily to the present. 2. Personal space is important. 3. Members may lightly touch another person’s hand during greetings. 4. Massage may be used for the newborn to pro- mote bonding between the infant and mother. 5. Some groups may prohibit touching of a dead body. D. Social roles 1. Members are family oriented. 2. The basic family unit is the extended family, which often includes persons from several households. 3. In some groups, grandparents are viewed as fam- ily leaders. 4. Elders are honored. 5. Children are taught to respect traditions. 6. The father usually does all work outside the home, and the mother assumes responsibility for domestic duties. 7. Sacred myths and legends provide spiritual guid- ance for some groups. 8. Most members adhere to some form of Chris- tianity, and religion and healing practices are usually integrated. 9. Community social organizations are important. E. Health and illness 1. Health is usually considered a state of harmony between the individual, family, and environment. 2. Some groups believe that illness is caused by supernatural forces and disequilibrium between the person and environment. 3. Traditional health and illness beliefs may con- tinue to be observed by some groups, including natural and religious folk medicine tradition. 4. For some groups, food preferences include corn- meal, fish, game, fruits, and berries. F. Health risks 1. Alcohol abuse 2. Obesity 3. Heart disease 4. Diabetes mellitus 5. Tuberculosis 6. Arthritis 7. Lactose intolerance 8. Gallbladder disease G. Interventions 1. Clarify communication. 2. Understand that the client may be attentive, even when eye contact is absent. 3. Be attentive to your own use of body language when caring for the client or family. 4. Obtain input from members of the extended family. 5. Encourage the client to personalize space in which health care is delivered; for example, encourage the client to bring personal items or objects to the hospital. 6. In the home, assess for the availability of running water, and modify infection control and hygiene practices as necessary. 7. Alternative modesofhealinginclude herbs, resto- ration ofbalance between the person and the uni- verse, and consultation with traditional healers. If language barriers pose a problem, seek a qualified medical interpreter; avoid using ancillary staff or family members as interpreters. VI. White Americans A. Description: Term used to include U.S. citizens or residents having origins in any of the original people of Europe, the Middle East, or North Africa; the term is interchangeable with Caucasian American. B. Communication 1. Languages include language of origin (e.g., Ital- ian, Polish, French, Russian) and English. 2. Silence can be used to show respect or disrespect for another, depending on the situation. 3. Eye contact is usually viewed as indicating trustworthiness in most origins. C. Time orientation and personal space preferences 1. Members are usually future oriented. 2. Time is valued; members tend to be on time and to be impatient with people who are not on time. 3. Some members may tend to avoid close physical contact. 4. Handshakes are usually used for formal greetings. D. Social roles 1. The nuclear family is the basic unit; the extended family is also important. 36 UNIT II Professional Standards in Nursing
- 55. F u n d a m e n t a l s 2. The man is usually the dominant figure, but a variation of gender roles exists within families and relationships. 3. Religions are varied, depending on origin. 4. Community social organizations are important. E. Health and illness 1. Health is usually viewed as an absence of disease or illness. 2. Many members usually have a tendency to be stoic when expressing physical concerns. 3. Members usually rely primarily on the modern Western health care delivery system. 4. Food preferences are based on origin; many members prefer foods containing carbohydrates and meat items. F. Health risks 1. Cancer 2. Heart disease 3. Diabetes mellitus 4. Obesity 5. Hypertension 6. Thalassemia G. Interventions 1. Assess the meaning of the client’s verbal and nonverbal behavior. 2. Respect the client’s personal space and time. 3. Be flexible and avoid rigidity in scheduling care. 4. Encourage family involvement. Some cultures believe that eye contact gives the other person an opening to see into, or to take, the soul. VII.End-of-Life Care (Box 5-2) A. People in the Jewish faith generally oppose prolong- ing life after irreversible brain damage. B. Some members of Eastern Orthodox religions, Muslims, and Orthodox Jews may prohibit, oppose, or discourage autopsy. C. Muslims permit organ transplant for the purpose of saving human life. D. The Amish permit organ donation with the exception ofheart transplants (the heart isthe soul ofthe body). E. Buddhists in the United States encourage organ donation and consider it an act of mercy. BOX 5-2 Religion and End-of-Life Care Christianity Amish Funerals are conducted in the home without a eulogy, flower decorations, or any other display; caskets are plain and simple, without adornment. At death, a woman is usually buried in her bridal dress. One is believed to live on after death, with either eternal reward in heaven or punishment in hell. Catholic and Orthodox A priest anoints the sick. Other sacraments before death include reconciliation and Holy Communion. Church of Jesus Christ of Latter-day Saints (Mormons) A sacrament may be administered if the client requests it. Protestant No last rites are provided (anointing of the sick is accepted by some groups). Prayers are given to offer comfort and support. Jehovah’s Witnesses Members are not allowed to receive a blood transfusion. Members believe that the soul cannot live after the body has died. Islam Second-degree male relatives such as cousins or uncles should be the contact people and determine whether the client or family should be given information about the client. The client may choose to face Mecca (west or southwest in the United States). The head should be elevated above the body. Discussions about death usually are not welcomed. Stopping medical treatment is against the will of Allah (Arabic word for God). Grief may be expressed through slapping or hitting the body. If possible, only a same-sex Muslim should handle the body after death; if not possible, non-Muslims should wear gloves so as not to touch the body. Judaism A client placed on life support should remain so until death. A dying person should not be left alone (a rabbi’s presence is desired). Autopsy and cremation are usually not allowed. Hinduism Rituals include tying a thread around the neck or wrist of the dying person, sprinkling the person with special water, and placing a leaf of basil on the person’s tongue. After death, the sacred threads are not removed, and the bodyis not washed. Buddhism A shrine to Buddha may be placed in the client’s room. Time for meditation at the shrine is important and should be respected. Clients may refuse medications that may alter their awareness (e.g., opioids). After death, a monk may recite prayers for 1 hour (need not be done in the presence of the body). 37 CHAPTER 5 Cultural Awareness and Health Practices
- 56. F u n d a m e n t a l s F. Some members of Mormon, Eastern Orthodox, Islamic, and Jewish (Conservative and Orthodox) faiths discourage, oppose, or prohibit cremation. G. Hindus usually prefer cremation and desire to cast the ashes in a holy river. H. African Americans 1. Members discuss issues with the spouse or older family member (elders are held in high respect). 2. Family is highly valued and is central to the care of terminally ill members. 3. Open displays of emotion are common and accepted. 4. Members prefer to die at home. I. Asian Americans 1. Family members may make decisions about care and often do not tell the client the diagnosis or prognosis. 2. Dying at home may be considered bad luck. 3. Organ donation may not be allowed in some ethnic groups. J. Hispanic and Latino groups 1. The family generally makes decisions and may request to withhold the diagnosis or prognosis from the client. 2. Extended-family members often are involved in end-of-life care (pregnant women may be pro- hibited from caring for dying clients or attending funerals). 3. Several family members may be at the dying client’s bedside. 4. Vocal expression of grief and mourning is accept- able and expected. 5. Members may refuse procedures that alter the body, such as autopsy. 6. Dying at home may be considered bad luck. K. Native Americans 1. Family meetings may be held to make decisions about end-of-life care and the type of treatments that should be pursued. 2. Some groups avoid contact with the dying (may prefer to die in the hospital). Provide individualized end-of-life care to the client and families. VIII. Complementary and Alternative Medicine (CAM) A. Description 1. Therapies are used in addition to conventional treatment to provide healing resources and focus on the mind-body connection. 2. High-risk therapies (therapies that are invasive) and low-risk therapies (those that are noninva- sive) are included in CAM. 3. The National Center for Complementary and Alternative Medicine (NCCAM) has proposed a classification system that includes 5 categories of complementary and alternative types of ther- apy (Box 5-3). B. Whole medical systems 1. Traditional Chinese medicine (TCM): Focuses on restoring and maintaining a balanced flow of vital energy; interventions include acupres- sure, acupuncture, herbal therapies, diet, medita- tion, tai chi, and qigong (exercise that focuses on breathing, visualization, and movement). 2. Ayurveda: Focuses on the balance of mind, body, and spirit; interventions include diet, medicinal herbs, detoxification, massage, breathing exer- cises, meditation, and yoga. 3. Homeopathy: Focuses on healing and interven- tions consisting of small doses of specially pre- pared plant and mineral extracts that assist in the innate healing process of the body. 4. Naturopathy: Focuses on enhancing the natural healing responses of the body; interventions include nutrition, herbology, hydrotherapy, acu- puncture, physical therapies, and counseling. C. Mind-body medicine 1. Mind-body medicine focuses on the interactions among the brain, mind, body, and behavior and on the powerful ways in which emotional, men- tal, social, spiritual, and behavioral factors can directly affect health. 2. Interventions include biofeedback, hypnosis, relaxation therapy, meditation, visual imagery, yoga, tai chi, qigong, cognitive-behavioral thera- pies, group supports, autogenic training, and spirituality. D. Biologically based practices (Box 5-4) 1. Biologically based therapies in CAM use sub- stances found in nature, such as herbs, foods, and vitamins. 2. Therapies include botanicals, prebiotics and pro- biotics, whole-food diets, functional foods, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, and proteins. E. Manipulative and body-based practices 1. Interventions involve manipulation and move- ment of the body by a therapist. 2. Interventions include practices such as chiro- practic and osteopathic manipulation, massage therapy, and reflexology. F. Energy medicine 1. Energy therapies focus on energy originating within the body or on energy from other sources. BOX 5-3 Categories of Complementary and Alternative Medicine ▪ Whole medical systems ▪ Mind-body medicine ▪ Biologically based practices ▪ Manipulative and body-based practices ▪ Energy medicine 38 UNIT II Professional Standards in Nursing
- 57. 2. Interventions include sound energy therapy, light therapy, acupuncture, qigong, Reiki and Johre, therapeutic touch, intercessory prayer, whole medical systems, and magnetic therapy. IX. Herbal Therapies (Box 5-5) A. Herbal therapy is the use of herbs (plant or a plant part) for their therapeutic value in promoting health. B. Some herbs have been determined to be safe, but some herbs, even in small amounts, can be toxic. C. If the client is taking prescription medications, the client should consult with the HCP regarding the use of herbs because serious herb-medication inter- actions can occur. D. Client teaching points 1. Discuss herbal therapies with the HCP before use. 2. Contact the HCP if any side effects of the herbal substance occur. 3. Contact the HCP before stopping the use of a prescription medication. 4. Avoid using herbs to treat a serious medical con- dition, such as heart disease. 5. Avoid taking herbs if pregnant or attempting to get pregnant or if nursing. 6. Do not give herbs to infants or young children. 7. Purchase herbal supplements only from a repu- table manufacturer; the label should contain the scientific name of the herb, name and address of the manufacturer, batch or lot num- ber, date of manufacture, and expiration date. 8. Adhere to the recommended dose; if herbal preparations are taken in high doses, they can be toxic. 9. Moisture, sunlight, and heat may alter the com- ponents of herbal preparations. 10. If surgery is planned, the herbal therapy may need to be discontinued 2 to 3 weeks before surgery. Some herbs have been determined to be safe, but some herbs, even in small amounts, can be toxic. Ask the client to discuss herbal therapies with the HCP before use. X. Low-Risk Therapies A. Low-risk therapies are therapies that have no adverse effects and, when implementing care, can be used by the nurse who has training and experience in their use. B. Common low-risk therapies 1. Meditation 2. Relaxation techniques 3. Imagery 4. Music therapy 5. Massage 6. Touch 7. Laughter and humor 8. Spiritual measures, such as prayer F u n d a m e n t a l s BOX 5-4 Biologically Based Practices Aromatherapy The use of topical or inhaled oils (plant extracts) that promote and maintain health Herbal Therapies The use of herbs derived mostlyfrom plant sources that main- tain and restore balance and health Macrobiotic Diet Diet high in whole-grain cereals, vegetables, beans, sea vege- tables, and vegetarian soups Elimination of meat, animal fat, eggs, poultry, dairyproducts, sugars, and artificially produced food from the diet Orthomolecular Therapy Focus on nutritional balance, including use of vitamins, essential amino acids, essential fats, and minerals BOX 5-5 Commonly Used Herbs and Health Products Aloe: Antiinflammatory and antimicrobial effect; accelerates wound healing Black cohosh: Produces estrogen-like effects Chamomile: Antispasmodic and antiinflammatory; produces mild sedative effect Dehydroepiandrosterone (DHEA): Converts to androgens and estro- gen; slows the effects of aging; used for erectile dysfunction Echinacea: Stimulates the immune system Garlic: Antioxidant; used to lower cholesterol levels Ginger: Antiemetic; used for nausea and vomiting Ginkgo biloba: Antioxidant; used to improve memory Ginseng: Increases physical endurance and stamina; used for stress and fatigue Glucosamine: Amino acid that assists in the synthesis of cartilage Melatonin: A hormone that regulates sleep; used for insomnia Milk thistle: Antioxidant; stimulates the production of new liver cells, reduces liver inflammation; used for liver and gallblad- der disease Peppermint oil: Antispasmodic; used for irritable bowel syndrome Saw palmetto: Antiestrogen activity; used for urinarytract infec- tions and benign prostatic hypertrophy St. John’s wort: Antibacterial, antiviral, antidepressant Valerian: Used to treat nervous disorders such as anxiety, restlessness, and insomnia 39 CHAPTER 5 Cultural Awareness and Health Practices
- 58. F u n d a m e n t a l s CRITICALTHINK ING W hat Should Y ou Do? Answer: Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body. The nurse should ask the client about the significance of such an item and its removal because it mayhave cultural or spiritual significance. The nurse should also determine whether the item will compromise client safety or the test results. If so, the nurse should ask the client if the item can be either removed temporarilyor placed on another part of the body during the procedure. Reference: Lewis et al. (2014), p. 25. P RACTI CE Q U ES TI O N S 1. The ambulatory care nurse is discussing preoperative procedureswith a JapaneseAmerican clientwho issched- uled for surgery the following week. During the discus- sion, the client continually smiles and nods the head. How should thenurse interpret thisnonverbalbehavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures 2. When communicating with a client who speaks a dif- ferent language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly. 3. The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example ofthe concept ofacculturation. The nurse edu- cator should make which most appropriate response? 1. “A group of individuals identifying as a part of the Iroquois tribe among Native Americans.” 2. “A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S.” 3. “A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal.” 4. “A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group.” 4. The nurse is providing discharge instructions to a Chi- nese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instruc- tions for the maintenance of health care. 5. A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client’s statements, which actions by the nurse demonstrate cultural sensitivity and spir- itual support? Select all that apply. 1. Ensures that a close kin stays with the client. 2. Makes a referral for a Catholic priest to visit the client. 3. Removes the crucifix from the wall in the client’s room. 4. Administers the sacrament of the sick to the cli- ent if death is imminent. 5. Offers to provide a means for praying the rosary if the client wishes. 6. Reminds the dietary department that meals served on Fridays during Lent do not contain meat. 6. Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. 1. Latino American man 2. Native American man 3. Asian American woman 4. Hispanic American man 5. African American woman 7. The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client’s religious preferences as being characteristic of a Jehovah’s Witness if which client statement is made? 1. “I cannot have surgery.” 2. “I cannot have any medicine.” 3. “I believe the soul lives on after death.” 4. “I cannot have any food containing or prepared with blood.” 8. Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1. Pork roast, rice, vegetables, mixed fruit, milk 2. Crab salad on a croissant, vegetables with dip, potato salad, milk 3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4. Noodles and cream sauce with shrimp and vegeta- bles, salad, mixed fruit, iced tea 40 UNIT II Professional Standards in Nursing
- 59. 9. An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang 10. Which is the best nursing intervention regarding complementary and alternative medicine? 1. Advising the client about “good” versus “bad” therapies 2. Discouraging the client from using any alterna- tive therapies 3. Educating the client about therapies that he or she is using or is interested in using 4. Identifying herbal remedies that the client should request from the health care provider 11. An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal sub- stance to help lower his blood pressure. The nurse should take which action? 1. Advise the client to read the labels of herbal ther- apies closely. 2. Tell the client that herbal substances are not safe and should never be used. 3. Encourage the client to discussthe use ofan herbal substance with the health care provider (HCP). 4. Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently. 12. The nurse educator asks a student to list the 5 main categories of complementary and alternative medi- cine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? 1. “CAM includes biologically based practices.” 2. “Whole medical systems are a component of CAM.” 3. “Mind-body medicine is part of the CAM approach.” 4. “Magnetic therapy and massage therapy are a focus of CAM.” AN S WERS 1. 1 Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of accep- tance of the treatment, agreement with the speaker, or under- standing of the procedure. Test-Taking Strategy: Eliminate options 2 and 3 first because they are comparable or alike and are incorrect. From the remaining options, note that the client is Japanese American and think about the characteristics of this group. This will direct you to option 1. In addition, option 4 is an incorrect interpretation of the client’s nonverbal behavior. Review: The cultural characteristics of Asian Americans Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Communication; Culture References: Giger (2013), p. 317; Jarvis (2016), p. 35. 2. 2 Rationale: Arranging for an interpreter would be the best prac- tice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it vio- lates privacy and does not ensure correct translation. Test-Taking Strategy: Note the strategic word, best, in the question and note the subject, communicating with a client of a different culture. Eliminate option 3 first because this action can constitute a violation of the client’s right to privacy, and does not represent best practice. Next, eliminate options 1 and 4, noting the word loudlyin these options and because they are nontherapeutic actions and also are not best practices. Review: Communication techniques for a client who speaks a different language Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Communication; Culture Reference: Jarvis (2016), pp. 45–46. 3. 2 Rationale: Acculturation is a process of learning a different cul- ture to adapt to a new or changing environment. Options 1 and 3 describe a subculture. Option 4 describes ethnic identity. Test-Taking Strategy: Note the strategic words, most appropri- ate. Focus on the subject, acculturation. Note the words a per- son who moves and adapts in the correct option and relate this to the definition of acculturation. Review: The definition of acculturation Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Culture; Professionalism Reference: Jarvis (2016), pp. 14–15. 4. 1 Rationale: Most Chinese Americans maintain a formal dis- tance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communica- tions, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is F u n d a m e n t a l s 41 CHAPTER 5 Cultural Awareness and Health Practices
- 60. to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading. Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the behavior of a Chinese American client. Elim- inate options 3 and 4 first because these actions are nonthera- peutic. To select from the remaining options, think about the cultural practices of Chinese Americans and recall that direct eye contact may be uncomfortable for the client. Review: The communication practices of Asian Americans Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Client Education; Culture Reference: Jarvis (2016), p. 36. 5. 1, 2, 5 Rationale: In times of illness, a Roman Catholic client may turn to prayer for spiritual support. This may include rosary prayers or visits from a priest, who is the spiritual leader in the Roman Catholic faith. Close family members usually want to stay with a dying family member in order to hear the wishes of the client, allowing the soul to leave in peace. Apriest, not a nurse, would administer the sacrament of the sick. Roman Catholics would not ask for the crucifix to be removed. Members of other reli- gious groups such as Islam or Judaism may request the removal of the crucifix. Dietary rituals are not a concern at this time. Test-Taking Strategy: Focus on the subject, the Roman Cath- olic religion. Consider the role of the spiritual leader and fam- ily in the Catholic faith. This will assist in selecting options 2 and 5. For the remaining options, recall that the presence of family is a source of support. Review: Spiritual and religious Hispanic clients Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Care Coordination; Culture Reference: Potter et al. (2015), pp. 111–112, 702–703. 6. 1, 2, 4, 5 Rationale: Because of their health and dietary practices, Latino Americans, Native Americans, Hispanic Americans, and Afri- can Americans have a high risk of obesity and diabetes melli- tus. Owing to dietary practices, Asian Americans have a lower risk for obesity and diabetes mellitus. Test-Taking Strategy: Focus on the subject, those with a high risk fordiabetesmellitusand obesity.Thinkaboutthehealth and dietary practices of each cultural group in the options to answer correctly. Review: The health risks for various ethnic groups Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Culture; Health Promotion Reference: Lewis et al. (2014), pp. 908, 1170. 7. 4 Rationale: Among Jehovah’s Witnesses, surgery is not prohib- ited, but the administration of blood and blood products is for- bidden. For a Jehovah’s Witness, administration of medication is an acceptable practice except if the medication is derived from blood products. This religious group believes that the soul cannot live after death. Jehovah’s Witnesses avoid foods prepared with or containing blood. Test-Taking Strategy: Focus on the subject, beliefs of Jeho- vah’s Witnesses. Remember that the administration of blood and any associated blood products is forbidden among Jeho- vah’s Witnesses. Even foods prepared with blood or containing blood are avoided. Review: The cultural preferences of Jehovah’s Witnesses Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Care Coordination; Culture Reference: Lewis et al. (2014), p. 677. 8. 3 Rationale: Members of Orthodox Judaism adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered. Test-Taking Strategy: Focus on the subject, dietary kosher laws, and recall that the dairy-meat combination is unaccept- able in the Orthodox Judaism group. Eliminate option 1 because this option contains pork roast and milk. Next, elim- inate options 2 and 4 because both options contain shellfish. Review: The dietary rules of members of the Orthodox Juda- ism religious group Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Cultural Awareness Priority Concept: Culture; Nutrition References: Giger (2013), pp. 516–517; Nix (2013), pp. 266–267. 9. 3 Rationale: In the Asian American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness (fever), and hot foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory. Test-Taking Strategy: Focus on the subject, an Asian Ameri- can, and the client’s diagnosis, fever. Remember that cold foods (yin foods) are eaten when one has a hot illness, and hot foods (yang foods) are eaten when one has a cold illness. Review: The health practices of the Asian American culture Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Cultural Awareness F u n d a m e n t a l s 42 UNIT II Professional Standards in Nursing
- 61. Priority Concept: Culture; Thermoregulation Reference: Jarvis (2016), pp. 18, 20. 10. 3 Rationale: Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client. Test-Taking Strategy: Note the strategic word, best. Use ther- apeutic communication techniques. Eliminate options 1, 2, and 4 because they are nontherapeutic. Also note that they are comparable or alike in that they provide advice to the client. Recommending an herbal remedy or discouraging a client from doing something is not within the role practices of the nurse. In addition, it is nontherapeutic to advise a client to do something. Review: Therapeutic communication techniques and the nurse’s role in educating clients about complementary and alternative medicine Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Client Education; Culture References: Lewis et al. (2014), pp. 85–86; Perry, Potter, Osten- dorf (2014), p. 31. 11. 3 Rationale: Although herbal substances may have some bene- ficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances because the combina- tion may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the HCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions. Test-Taking Strategy: Eliminate option 2 first because of the closed-ended word never. Next, eliminate options 1 and 4 because they are comparable or alike and indicate acceptance of using an herbal substance. Review: The limitations associated with the use of herbal substances Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Client Education; Safety Reference: Lewis et al. (2014), pp. 81, 85–86. 12. 4 Rationale: The 5 main categories of CAM include whole med- ical systems, mind-body medicine, biologically based prac- tices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM. Test-Taking Strategy: Note the strategic words, need for fur- ther teaching. These words indicate a negative event query and the need to select the incorrect option. Also, focus on the subject of the question, the 5 main categories of CAM. Not- ing that the question asks about main categories, not specific therapies, will assist in directing you to the correct option. Review: The categories of complementary and alternative medicine Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Cultural Awareness Priority Concepts: Clinical Judgment; Safety Reference: Lewis et al. (2014), p. 80. F u n d a m e n t a l s 43 CHAPTER 5 Cultural Awareness and Health Practices
- 62. F u n d a m e n t a l s CH AP TER 6 Ethical and Legal Issues PRIORITYCONCEPTS Ethics; Health Care Law CRITICALTHINK ING W hat Should Y ou Do? While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: “I have changed my mind. I don’t want this surgery.” What should the nurse do? Answer located on p. 54. I. Ethics A. Description: The branch of philosophy concerned with the distinction between right and wrong on the basis of a body of knowledge, not only on the basis of opinions B. Morals: Behavior in accordance with customs or tra- dition, usually reflecting personal or religious beliefs C. Ethicalprinciples: Codes that direct or govern nursing actions (Box 6-1) D. Values: Beliefs and attitudes that may influence behavior and the process of decision making E. Values clarification: Process of analyzing one’s own values to understand oneself more completely regarding what is truly important F. Ethical codes 1. Ethical codes provide broad principles for deter- mining and evaluating client care. 2. These codes are not legally binding, but the board of nursing has authority in most states to reprimand nurses for unprofessional conduct that results from violation of the ethical codes. 3. Specific ethical codes are as follows: a. The Code of Ethics for Nurses developed by the International Council of Nurses; Web site: http://www.icn.ch/about-icn/code-of-ethics- for-nurses/. b. The American Nurses Association Code of Ethics can be viewed on the American Nurses Association Web site: http://www. nursingworld.org/codeofethics. G. Ethical dilemma 1. An ethical dilemma occurs when there is a con- flict between 2 or more ethical principles. 2. No correct decision exists, and the nurse must make a choice between 2 alternatives that are equally unsatisfactory. 3. Such dilemmas may occur as a result of differ- ences in cultural or religious beliefs. 4. Ethical reasoningisthe processofthinkingthrough what one should do in an orderly and systematic manner to provide justification for actions based on principles; the nurse should gather all informa- tion to determinewhetheran ethicaldilemmaexists, examine his or her own values, verbalize the prob- lem, consider possible courses of action, negotiate the outcome, and evaluate the action taken. H. Advocate 1. An advocate is a person who speaks up for or acts on the behalf of the client, protects the client’s right to make his or her own decisions, and upholds the principle of fidelity. 2. An advocate represents the client’s viewpoint to others. 3. An advocate avoids letting personal values influ- ence advocacy for the client and supports the cli- ent’s decision, even when it conflicts with the advocate’s own preferences or choices. I. Ethics committees 1. Ethics committees take an interprofessional approach to facilitate dialogue regarding ethical dilemmas. 2. These committees develop and establish policies and procedures to facilitate the prevention and resolution of dilemmas. An important nursing responsibility is to act as a client advocate and protect the client’s rights. II. Regulation of Nursing Practice A. Nurse Practice Act 1. Anurse practice act is a series of statutes that have been enacted by each state legislature to regulate the practice of nursing in that state. 2. Nurse practice acts set educational requirements for the nurse, distinguish between nursing 44
- 63. F u n d a m e n t a l s practice and medical practice, and define the scope of nursing practice. 3. Additional issues covered by nurse practice acts include licensure requirements for protection of the public, grounds for disciplinary action, rights of the nurse licensee if a disciplinary action is taken, and related topics. 4. All nurses are responsible for knowing the provi- sions of the act of the state or province in which they work. B. Standards of care 1. Standards of care are guidelines that identify what the client can expect to receive in terms of nursing care. 2. The guidelines determine whether nurses have performed duties in an appropriate manner. 3. If the nurse does not perform duties within accepted standards of care, the nurse places him- self or herself in jeopardy of legal action. 4. If the nurse is named as a defendant in a malprac- tice lawsuit and proceedings show that the nurse followed neither the accepted standards of care outlined by the state or province nurse practice act nor the policies of the employing institution, the nurse’s legal liability is clear; he or she is liable. C. Employee guidelines 1. Respondeat superior: The employer is held liable for any negligent acts of an employee if the alleged negligent act occurred during the employment relationship and was within the scope of the employee’s responsibilities. 2. Contracts a. Nurses are responsible for carrying out the terms of a contractual agreement with the employing agency and the client. b. The nurse-employee relationship is governed by established employee handbooks and cli- ent care policies and procedures that create obligations, rights, and duties between those parties. 3. Institutional policies a. Written policies and procedures of the employing institution detail how nurses are to perform their duties. b. Policies and procedures are usually specific and describe the expected behavior on the part of the nurse. c. Although policies are not laws, courts gener- ally rule against nurses who violate policies. d. If the nurse practices nursing according to cli- ent care policies and procedures established by the employer, functions within the job responsibility, and provides care consistently in a nonnegligent manner, the nurse mini- mizes the potential for liability. The nurse must follow the guidelines identified in the Nurse Practice Act and agency policies and proce- dures when delivering client care. D. Hospital staffing 1. Charges of abandonment may be made against nurses who “walk out” when staffing is inadequate. 2. Nurses in short staffing situations are obligated to make a report to the nursing administration. E. Floating 1. Floating is an acceptable practice used by health care facilities to alleviate understaffing and overstaffing. 2. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove lack of knowledge for the performance of assigned tasks. 3. Nurses in a floating situation must not assume responsibility beyond their level of experience or qualification. 4. Nurses who float should inform the supervisor of any lack of experience in caring for the type of clients on the new nursing unit. 5. A resource nurse who is skilled in the care of clients on the unit should also be assigned to the float nurse; in addition, the float nurse should be given an orientation of the unit and the standards of care for the unit should be reviewed (the float nurse can care for “overflow” clients whose acuity level more closely match the nurses’ experience). F. Disciplinary action 1. Boards of nursing may deny, revoke, or suspend any license to practice as a registered nurse, according to their statutory authority. 2. Some causes for disciplinary action are as follows: a. Unprofessional conduct b. Conduct that could affect the health and wel- fare of the public adversely BOX 6-1 Ethical Principles Autonomy: Respect for an individual’s right to self-determi- nation Nonmaleficence: The obligation to do or cause no harm to another Beneficence: The duty to do good to others and to maintain a balance between benefits and harms; paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for the client and encourages the client to act against his or her own choices Justice: The equitable distribution of potential benefits and tasks determining the order in which clients should be cared for Veracity: The obligation to tell the truth Fidelity: The duty to do what one has promised 45 CHAPTER 6 Ethical and Legal Issues
- 64. c. Breach of client confidentiality d. Failure to use sufficient knowledge, skills, or nursing judgment e. Physically or verbally abusing a client f. Assumingdutieswithout sufficient preparation g. Knowingly delegating to unlicensed person- nel nursing care that places the client at risk for injury h. Failure to maintain an accurate record for each client i. Falsifying a client’s record j. Leaving a nursing assignment without prop- erly notifying appropriate personnel III. Legal Liability A. Laws 1. Nurses are governed by civil and criminal law in roles as providers of services, employees of insti- tutions, and private citizens. 2. The nurse has a personal and legal obligation to provide a standard of client care expected of a reasonably competent professional nurse. 3. Professional nurses are held responsible (liable) for harm resulting from their negligent acts or their failure to act. B. Types of laws (Box 6-2; Fig. 6-1) C. Negligence and malpractice (Box 6-3) 1. Negligence is conduct that falls below the stan- dard of care. 2. Negligence can include acts of commission and acts of omission. 3. The nurse who does not meet appropriate stan- dards of care may be held liable. 4. Malpractice is negligence on the part of the nurse. 5. Malpractice is determined if the nurse owed a duty to the client and did not carry out the duty and the client was injured because the nurse failed to perform the duty. 6. Proof of liability a. Duty: At the time of injury, a duty existed between the plaintiff and the defendant. b. Breach of duty: The defendant breached duty of care to the plaintiff. c. Proximate cause: The breach of the duty was the legal cause of injury to the client. F u n d a m e n t a l s BOX 6-2 Types of Law Contract Law Contract law is concerned with enforcement of agreements among private individuals. Civil Law Civil law is concerned with relationships among persons and the protection of a person’s rights. Violation maycause harm to an individual or property, but no grave threat to society exists. Criminal Law Criminal law is concerned with relationships between individ- uals and governments, and with acts that threaten societyand its order; a crime is an offense against society that violates a law and is defined as a misdemeanor (less serious nature) or felony (serious nature). Tort Law Atort is a civil wrong, other than a breach in contract, in which the law allows an injured person to seek damages from a per- son who caused the injury. The Cons titution Types of law applicable to nurs es Statutory law Common law Private law Administrative law Legislative branch Intentional (action is substantially certain to cause an effect) • Fraud • Defamation • Assault and battery • False imprisonment • Invasion of privacy • Negligence • Malpractice Unintentional (violation of standard of care) Judicial branch Standard of proof is preponderance of the evidence Standard of proof is guilt beyond a reasonable doubt Civil • Nurse-patient relationship Contracts Torts • Manslaughter • Assault and battery • Fraud Felony Misdemeanor Criminal Executive branch Sources of Law (the balance of power) • Procedural law • Public law • Substantive law FIGURE 6-1 Sources of law for nursing practice. 46 UNIT II Professional Standards in Nursing
- 65. F u n d a m e n t a l s d. Damage or injury: The plaintiff experienced injury or damages or both and can be com- pensated by law. The nurse must meet appropriate standards ofcare when delivering care to the client; otherwise the nurse would be held liable if the client is harmed. D. Professional liability insurance 1. Nurses need their own liability insurance for pro- tection against malpractice lawsuits. 2. Having their own insurance provides nurses pro- tection as individuals; this allows the nurse to have an attorney, who has only the nurse’s inter- ests in mind, present if necessary. E. Good Samaritan laws 1. State legislatures pass Good Samaritan laws, which may vary from state to state. 2. These laws encourage health care professionals to assist in emergency situations and limit liabil- ity and offer legal immunity for persons helping in an emergency, provided that they give reasonable care. 3. Immunity from suit applies only when all condi- tions of the state law are met, such as that the health care provider (HCP) receives no compen- sation for the care provided and the care given is not intentionally negligent. F. Controlled substances 1. The nurse should adhere to facility policies and procedures concerning administration of con- trolled substances, which are governed by federal and state laws. 2. Controlled substances must be kept locked securely, and only authorized personnel should have access to them. 3. Controlled substances must be properly signed out for administration and a correct inventory must be maintained. IV. Collective Bargaining A. Collective bargaining is a formalized decision- making process between representatives of manage- ment and representatives of labor to negotiate wages and conditions of employment. B. When collective bargaining breaks down because the parties cannot reach an agreement, the employees may call a strike or take other work actions. C. Striking presents a moral dilemma to many nurses because nursing practice is a service to people. V. Legal Risk Areas A. Assault 1. Assault occurs when a person puts another per- son in fear of a harmful or offensive contact. 2. The victim fears and believes that harm will result because of the threat. B. Battery is an intentional touching of another’s body without the other’s consent. C. Invasion of privacy includes violating confidentiality, intrudingon private client or familymatters, and shar- ing client information with unauthorized persons. D. False imprisonment 1. False imprisonment occurs when a client is not allowed to leave a health care facility when there is no legal justification to detain the client. 2. False imprisonment also occurs when restraining devices are used without an appropriate clinical need. 3. Aclient can sign an Against Medical Advice form when the client refuses care and is competent to make decisions. 4. The nurse should document circumstances in the medical record to avoid allegations by the client that cannot be defended. E. Defamation is a false communication that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). F. Fraud results from a deliberate deception intended to produce unlawful gains. G. There may be exceptions to certain legal risks areas, such as assault, battery, and false imprisonment, when caring for a client with a mental health disor- der experiencing acute distress who poses a risk to himself or herself or others. In this situation, the nurse must assess the client to determine loss of con- trol and intervene accordingly; the nurse should use the least restrictive methods initially, but then use interventions such as restraint if the client’s behavior indicates the need for this intervention. VI. Client’s Rights A. Description 1. The client’s rights document, also called the Cli- ent’s (Patient’s) Bill of Rights, reflects acknowledg- ment of a client’s right to participate in her or his health care with an emphasis on client autonomy. BOX 6-3 Examples of Negligent Acts ▪ Medication errors that result in injury to the client ▪ Intravenous administration errors, such as incorrect flow rates or failure to monitor a flow rate, that result in injury to the client ▪ Falls that occur as a result of failure to provide safetyto the client ▪ Failure to use sterile technique when indicated ▪ Failure to check equipment for proper functioning ▪ Burns sustained by the client as a result of failure to mon- itor bath temperature or equipment ▪ Failure to monitor a client’s condition ▪ Failure to report changes in the client’s condition to the health care provider ▪ Failure to provide a complete report to the oncoming nurs- ing staff Adapted from Potter P, PerryA, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 47 CHAPTER 6 Ethical and Legal Issues
- 66. 2. The document provides a list of the rights of the client and responsibilities that the hospital can- not violate (Box 6-4). 3. The client’s rights protect the client’s ability to determine the level and type of care received; all health care agencies are required to have a Client’s Bill of Rights posted in a visible area. 4. Several laws and standards pertain to client’s rights (Box 6-5). B. Rights for the mentally ill (Box 6-6) 1. The Mental Health Systems Act created rights for mentally ill people. 2. The Joint Commission has developed policy statements on the rights of mentally ill people. 3. Psychiatric facilities are required to have a Cli- ent’s Bill of Rights posted in a visible area. C. Organ donation and transplantation 1. A client has the right to decide to become an organ donor and a right to refuse organ trans- plantation as a treatment option. 2. An individual who is at least 18 years old may indicate a wish to become a donor on his or her driver’s license (state-specific) or in an advance directive. 3. The Uniform Anatomical Gift Act provides a list of individuals who can provide informed consent for the donation of a deceased individual’s organs. 4. The United Network for Organ Sharing sets the criteria for organ donations. 5. Some organs, such as the heart, lungs, and liver, can be obtained only from a person who is on mechanical ventilation and has suffered brain death, whereas other organs or tissues can be removed several hours after death. 6. A donor must be free of infectious disease and cancer. 7. Requests to the deceased’s family for organ dona- tion usually are done by the HCP or nurse spe- cially trained for making such requests. 8. Donation of organs does not delay funeral arrangements; no obvious evidence that the organs were removed from the body shows when F u n d a m e n t a l s BOX 6-4 Client’s Rights When Hospitalized ▪ Right to considerate and respectful care ▪ Right to be informed about diagnosis, possible treatments, and likely outcome, and to discuss this information with the health care provider ▪ Right to know the names and roles of the persons who are involved in care ▪ Right to consent or refuse a treatment ▪ Right to have an advance directive ▪ Right to privacy ▪ Right to expect that medical records are confidential ▪ Right to review the medical record and to have information explained ▪ Right to expect that the hospital will provide necessary health services ▪ Right to know if the hospital has relationships with outside parties that may influence treatment or care ▪ Right to consent or refuse to take part in research ▪ Right to be told of realistic care alternatives when hospital care is no longer appropriate ▪ Right to know about hospital rules that affect treatment, and about charges and payment methods From Christensen B, KockrowE: Foundationsofnursing, ed 6, St. Louis, 2010, Mosby; and adapted from American Hospital Association: The patient care partnership: understanding expectations, rights and responsibilities. Available at www.aha.org/ content/00-10/pcp_english_030730.pdf. BOX 6-5 Laws and Standards American Hospital Association Issued Patient’s Bill of Rights American Nurses Association Developed the Code of Ethics for Nurses, which defines the nurse’s responsibility for upholding client’s rights Mental Health Systems Act Developed rights for mentally ill clients The Joint Commission Developed policy statements on the rights of mentally ill individuals BOX 6-6 Rights for the Mentally Ill ▪ Right to be treated with dignity and respect ▪ Right to communicate with persons outside the hospital ▪ Right to keep clothing and personal effects with them ▪ Right to religious freedom ▪ Right to be employed ▪ Right to manage property ▪ Right to execute wills ▪ Right to enter into contractual agreements ▪ Right to make purchases ▪ Right to education ▪ Right to habeas corpus (written request for release from the hospital) ▪ Right to an independent psychiatric examination ▪ Right to civil service status, including the right to vote ▪ Right to retain licenses, privileges, or permits ▪ Right to sue or be sued ▪ Right to marry or divorce ▪ Right to treatment in the least restrictive setting ▪ Right not to be subject to unnecessary restraints ▪ Right to privacy and confidentiality ▪ Right to informed consent ▪ Right to treatment and to refuse treatment ▪ Right to refuse participation in experimental treatments or research Adapted from Stuart G: Principles and practice of psychiatric nursing, ed 10, St. Louis, 2013, Mosby. 48 UNIT II Professional Standards in Nursing
- 67. the body is dressed; and the family incurs no cost for removal of the organs donated. D. Religious beliefs: Organ donation and transplan- tation 1. Catholic Church: Organ donation and trans- plants are acceptable. 2. Orthodox Church: Church discourages organ donation. 3. Islam (Muslim) beliefs: Body parts may not be removed or donated for transplantation. 4. Jehovah’s Witness: An organ transplant may be accepted, but the organ must be cleansed with a nonblood solution before transplantation. 5. Orthodox Judaism a. All body parts removed during autopsy must be buried with the body because it is believed that the entire body must be returned to the earth; organ donation may not be considered by family members. b. Organ transplantation may be allowed with the rabbi’s approval. 6. Refer to Chapter 5 for additional information regarding end-of-life care. VII.Informed Consent A. Description 1. Informed consent is the client’s approval (or that of the client’s legal representative) to have his or her body touched by a specific individual. 2. Consents, or releases, are legal documents that indicate the client’s permission to perform sur- gery, perform a treatment or procedure, or give information to a third party. 3. There are different types of consents (Box 6-7). 4. Informed consent indicates the client’s participa- tion in the decision regarding health care. 5. The client must be informed, in understandable terms, of the risks and benefits of the surgery or treatment, what the consequences are for not having the surgery or procedure performed, treat- ment options, and the name of the health care provider performing the surgery or procedure. 6. A client’s questions about the surgery or proce- dure must be answered before signing the consent. 7. A consent must be signed freely by the client without threat or pressure and must be witnessed (the witness must be an adult). 8. A client who has been medicated with sedating medications or any other medications that can affect the client’s cognitive abilities must not be asked to sign a consent. 9. Legally, the client must be mentally and emo- tionally competent to give consent. 10. If a client is declared mentally or emotionally incompetent, the next of kin, appointed guard- ian (appointed by the court), or durable power of attorney for health care has legal authority to give consent (Box 6-8). 11. A competent client 18 years of age or older must sign the consent. 12. In most states, when the nurse is involved in the informed consent process, the nurse is witnes- sing only the signature of the client on the informed consent form. F u n d a m e n t a l s BOX 6-7 Types of Consents Admission Agreement Admission agreements are obtained at the time of admission and identify the health care agency’s responsibility to the client. Immunization Consent An immunization consent may be required before the admin- istration of certain immunizations; the consent indicates that the client was informed of the benefits and risks of the immunization. Blood Transfusion Consent A blood transfusion consent indicates that the client was informed ofthe benefits and risks ofthe transfusion. Some cli- ents hold religious beliefs that would prohibit them from receiving a blood transfusion, even in a life-threatening situation. Surgical Consent Surgical consent is obtained for all surgical or invasive proce- dures or diagnostic tests that are invasive. The health care pro- vider, surgeon, or anesthesiologist who performs the operative or other procedure is responsible for explaining the procedure, its risks and benefits, and possible alternative options. Research Consent The research consent obtains permission from the client regarding participation in a research study. The consent informs the client about the possible risks, consequences, and benefits of the research. Special Consents Special consents are required for the use of restraints, photo- graphing the client, disposal of body parts during surgery, donating organs after death, or performing an autopsy. BOX 6-8 Mentally or Emotionally Incompetent Clients ▪ Declared incompetent ▪ Unconscious ▪ Under the influence of chemical agents such as alcohol or drugs ▪ Chronic dementia or other mental deficiency that impairs thought processes and ability to make decisions 49 CHAPTER 6 Ethical and Legal Issues
- 68. 13. An informed consent can be waived for urgent medical or surgical intervention as long as insti- tutional policy so indicates. 14. A client has the right to refuse information and waive the informed consent and undergo treat- ment, but this decision must be documented in the medical record. 15. A client may withdraw consent at any time. An informed consent is a legal document, and the client must be informed bythe HCP (i.e., physician, sur- geon), in understandable terms, ofthe risks and benefits of surgery, treatments, procedures, and plan of care. The client needs to be a participant in decisions regarding health care. B. Minors 1. A minor is a client under legal age as defined by state statute (usually younger than 18 years). 2. Aminor may not give legal consent, and consent must be obtained from a parent or the legal guardian; assent by the minor is important because it allows for communication of the minor’s thoughts and feelings. 3. Parental or guardian consent should be obtained before treatment is initiated for a minor except in the following cases: in an emergency; in situations in which the consent of the minor is sufficient, including treatment related to sub- stance abuse, treatment of a sexually transmitted infection, human immunodeficiency virus (HIV) testing and acquired immunodeficiency syn- drome (AIDS) treatment, birth control services, pregnancy, or psychiatric services; the minor is an emancipated minor; or a court order or other legal authorization has been obtained. Refer to the Guttmacher Report on Public Policy for addi- tional information: http://www.guttmacher.org/ pubs/tgr/03/4/gr030404.html. C. Emancipated minor 1. An emancipated minor has established indepen- dence from his or her parents through marriage, pregnancy, or service in the armed forces, or by a court order. 2. An emancipated minor is considered legally capable of signing an informed consent. VIII. Health Insurance Portability and Accountability Act A. Description 1. The Health Insurance Portability and Account- ability Act (HIPAA) describes how personal health information (PHI) may be used and how the client can obtain access to the information. 2. PHI includes individually identifiable informa- tion that relates to the client’s past, present, or future health; treatment; and payment for health care services. 3. The act requires health care agencies to keep PHI private, provides information to the client about the legal responsibilities regarding privacy, and explains the client’s rights with respect to PHI. 4. The client has various rights as a consumer of health care under HIPAA, and any client requests may need to be placed in writing; a fee may be attached to certain client requests. 5. The client may file a complaint if the client believes that privacy rights have been violated. B. Client’s rights include the right to do the following: 1. Inspect a copy of PHI. 2. Ask the health care agency to amend the PHI that is contained in a record if the PHI is inaccurate. 3. Request a list of disclosures made regarding the PHI as specified by HIPAA. 4. Request to restrict how the health care agency uses or discloses PHI regarding treatment, payment, or health care services, unless infor- mation is needed to provide emergency treatment. 5. Request that the health care agency communi- cate with the client in a certain way or at a certain location; the request must specify how or where the client wishes to be contacted. 6. Request a paper copy of the HIPAA notice. C. Health care agency use and disclosure of PHI 1. The health care agency obtains PHI in the course of providing or administering health insurance benefits. 2. Use or disclosure of PHI may be done for the following: a. Health care payment purposes b. Health care operations purposes c. Treatment purposes d. Providing information about health care services e. Data aggregation purposes to make health care benefit decisions f. Administering health care benefits 3. There are additional uses or disclosures of PHI (Box 6-9). IX. Confidentiality/Information Security A. Description 1. In the health care system, confidentiality/informa- tion security refers to the protection of privacy of the client’s PHI. 2. Clients have a right to privacy in the health care system. 3. A special relationship exists between the client and nurse, in which information discussed is not shared with a third party who is not directly involved in the client’s care. 4. Violations of privacy occur in various ways (Box 6-10). F u n d a m e n t a l s 50 UNIT II Professional Standards in Nursing
- 69. F u n d a m e n t a l s B. Nurse’s responsibility 1. Nurses are bound to protect client confidentiality by most nurse practice acts, by ethical principles and standards, and by institutional and agency policies and procedures. 2. Disclosure of confidential information exposes the nurse to liability for invasion of the client’s privacy. 3. The nurse needs to protect the client from indis- criminate disclosure of health care information that may cause harm (Box 6-11). C. Social networks and health care (Box 6-12) D. Medical records 1. Medical records are confidential. 2. The client has the right to read the medical record and have copies of the record. 3. Only staff members directly involved in care have legitimate access to a client’s record; these may include HCPs and nurses caring for the cli- ent, technicians, therapists, social workers, unit secretaries, client advocates, and administrators (e.g., for statistical analysis, staffing, quality care review). Others must ask permission from the client to review a record. BOX 6-9 Uses or Disclosures of Personal Health Information ▪ Compliance with legal proceedings or for limited law enforcement purposes ▪ To a family member or significant other in a medical emergency ▪ To a personalrepresentative appointed bythe client or des- ignated by law ▪ For research purposes in limited circumstances ▪ To a coroner, medical examiner, or funeral director about a deceased person ▪ To an organ procurement organization in limited circumstances ▪ To avert a serious threat to the client’s health or safety or the health or safety of others ▪ To a governmental agencyauthorized to oversee the health care system or government programs ▪ To the Department of Health and Human Services for the investigation of compliance with the Health Insurance Por- tability and Accountability Act or to fulfill another lawful request ▪ To federal officials for lawful intelligence or national secu- rity purposes ▪ To protect health authorities for public health purposes ▪ To appropriate military authorities if a client is a member of the armed forces ▪ In accordance with a valid authorization signed by the client Adapted from U.S. Department of Health and Human Services Office for Civil Rights: Health information privacy. Available at http://www.hhs.gov/ocr/privacy/. BOX 6-10 Violations and Invasion of Client Privacy ▪ Taking photographs of the client ▪ Release ofmedical information to an unauthorized person, such as a member of the press, family, friend, or neighbor of the client, without the client’s permission ▪ Use of the client’s name or picture for the health care agency’s sole advantage ▪ Intrusion by the health care agency regarding the client’s affairs ▪ Publication of information about the client or photographs of the client, including on a social networking site ▪ Publication of embarrassing facts ▪ Public disclosure of private information ▪ Leaving the curtains or room door open while a treatment or procedure is being performed ▪ Allowing individuals to observe a treatment or procedure without the client’s consent ▪ Leaving a confused or agitated client sitting in the nursing unit hallway ▪ Interviewing a client in a room with onlya curtain between clients or where conversation can be overheard ▪ Accessing medical records when unauthorized to do so BOX 6-11 Maintenance of Confidentiality ▪ Not discussing client issues with other clients or staffunin- volved in the client’s care ▪ Not sharing health care information with others without the client’s consent (includes family members or friends of the client and social networking sites) ▪ Keeping all information about a client private, and not revealing it to someone not directly involved in care ▪ Discussing client information onlyin private and secluded areas ▪ Protecting the medical record from all unauthorized readers BOX 6-12 Social Networking and Health Care ▪ Specific social networking sites can be beneficial to health care providers (HCPs) and clients; misuse of social net- working sites bythe HCP can lead to Health Insurance Por- tability and Accountability Act (HIPAA) violations and subsequent termination of the employee. ▪ Nurses need to adhere to the code of ethics, confidentiality rules, and social media rules. Additional information about these codes and rules can be located at the American Nurses Association Web site at http://www.nursingworld. org/FunctionalMenuCategories/AboutANA/Social-Media/ Social-Networking-Principles-Toolkit. ▪ Standards of professionalism need to be maintained and any information obtained through any nurse-client rela- tionship cannot be shared in any way. ▪ The nurse is responsible for reporting anyidentified breach of privacy or confidentiality. 51 CHAPTER 6 Ethical and Legal Issues
- 70. 4. The medical record is stored in the records or the health information department after discharge of the client from the health care facility. E. Information technology/computerized medical records 1. Health care employees should have access only to the client’s records in the nursing unit or work area. 2. Confidentiality/information security can be pro- tected by the use of special computer access codes to limit what employees have access to in com- puter systems. 3. The use of a password or identification code is needed to enter and sign off a computer system. 4. A password or identification code should never be shared with another person. 5. Personal passwords should be changed periodi- cally to prevent unauthorized computer access. F. When conducting research, any information pro- vided by the client is not to be reported in any man- ner that identifies the client and is not to be made accessible to anyone outside the research team. The nurse must always protect client confidentiality. X. Legal Safeguards A. Risk management 1. Risk management is a planned method to iden- tify, analyze, and evaluate risks, followed by a plan for reducing the frequency of accidents and injuries. 2. Programs are based on a systematic reporting sys- tem for incidents or unusual occurrences. B. Incident reports (Box 6-13) 1. The incident report is used as a means of identi- fying risk situations and improving client care. 2. Follow specific documentation guidelines. 3. Fill out the report completely, accurately, and factually. 4. The report form should not be copied or placed in the client’s record. 5. Make no reference to the incident report form in the client’s record. 6. The report is not a substitute for a complete entry in the client’s record regarding the incident. 7. If a client injury or error in care occurred, assess the client frequently. 8. The health care provider must be notified of inci- dent and the client’s condition. C. Safeguarding valuables 1. Client’s valuables should be given to a family member or secured for safekeeping in a stored and locked designated location, such as the agency’s safe; the location of the client’s valu- ables should be documented per agency policy. 2. Many health care agencies require a client to sign a release to free the agency of the responsibility for lost valuables. 3. A client’s wedding band can be taped in place unless a risk exists for swelling of the hands or fingers. 4. Religious items, such as medals, may be pinned to the client’s gown if allowed by agency policy. D. HCP’s prescriptions 1. The nurse is obligated to carry out an HCP’s pre- scription except when the nurse believes a pre- scription to be inappropriate or inaccurate. 2. The nurse carrying out an inaccurate prescription may be legally responsible for any harm suffered by the client. 3. If no resolution occurs regarding the prescription in question, the nurse should contact the nurse manager or supervisor. 4. The nurse should follow specific guidelines for telephone prescriptions (Box 6-14). 5. The nurse should ensure that all components of a medication prescription are documented (Box 6-15). The nurse should never carryout a prescription if it is unclear or inappropriate. The HCP should be con- tacted immediately. E. Documentation 1. Documentation is legally required by accrediting agencies, state licensing laws, and state nurse and medical practice acts. F u n d a m e n t a l s BOX6-13 Examples of Incidents That Need to Be Reported ▪ Accidental omission of prescribed therapies ▪ Circumstances that led to injury or a risk for client injury ▪ Client falls ▪ Medication administration errors ▪ Needle-stick injuries ▪ Procedure-related or equipment-related accidents ▪ A visitor injury that occurred on the health care agency premises ▪ Avisitor who exhibits symptoms ofa communicable disease BOX 6-14 Telephone Prescription Guidelines ▪ Date and time the entry. ▪ Repeat the prescription to the health care provider (HCP), and record the prescription. ▪ Sign the prescription; begin with “t.o.” (telephone order), write the HCP’s name, and sign the prescription. ▪ If another nurse witnessed the prescription, that nurse’s signature follows. ▪ The HCP needs to countersign the prescription within a timeframe according to agency policy. 52 UNIT II Professional Standards in Nursing
- 71. F u n d a m e n t a l s 2. The nurse should follow agency guidelines and procedures (Box 6-16). 3. Refer to The Joint Commission Web site for acceptable abbreviations and documentation guidelines: http://www.jointcommission.org/ standards_information/npsgs.aspx. F. Client and family teaching 1. Provide complete instructions in a language that the client or family can understand. 2. Document client and family teaching, what was taught, evaluation of understanding, and who was present during the teaching. 3. Inform the client of what could happen if infor- mation shared during teaching is not followed. XI. Advance Directives A. Client (Patient) Self-Determination Act 1. The Client (Patient) Self-Determination Act is a law that indicates clients must be provided with information about their rights to identify written directions about the care that they wish to receive in the event that they become incapacitated and are unable to make health care decisions. 2. On admission to a health care facility, the client is asked about the existence of an advance direc- tive, and if one exists, it must be documented and included as part of the medical record; if the cli- ent signs an advance directive at the time of admission, it must be documented in the client’s medical record. 3. The 2 basic types of advance directives include instructional directives and durable power of attorney for health care. a. Instructional directives: Lists the medical treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. b. Durable power of attorney for health care: Appoints a person (health care proxy) chosen by the client to make health care decisions on the client’s behalf when the client can no lon- ger make decisions. B. Do not resuscitate (DNR) orders 1. A DNR order should be written if the client and health care provider have made the decision that the client’s health is deteriorating and the client chooses not to undergo cardiopulmonary resus- citation if needed. 2. The client or his or her legal representative must provide informed consent for the DNR status. 3. The DNR order must be defined clearly so that other treatment, not refused by the client, will be continued. 4. Some states offer DNR Comfort Care and DNR Comfort Care Arrest protocols; these protocols list specific actions that HCPs will take when pro- viding cardiopulmonary resuscitation (CPR). 5. All health care personnel must know whether a client has a DNR order; if a client does not have a DNR order, HCPs need to make every effort to revive the client. 6. A DNR order needs to be reviewed regularly according to agency policy and may need to be changed if the client’s status changes. 7. DNR protocols may vary from state to state, and it is important for the nurse to know his or her state’s protocols. C. The nurse’s role 1. Discussingadvance directives with the client opens the communication channel to establish what is important to the client and what the client may view as promoting life versus prolonging dying. BOX 6-15 Components of a Medication Prescription ▪ Date and time prescription was written ▪ Medication name ▪ Medication dosage ▪ Route of administration ▪ Frequency of administration ▪ Health care provider’s signature BOX 6-16 Do’s and Don’ts Documentation Guidelines: Narrative and Information Technology ▪ Use a black-colored ink pen for narrative documentation. ▪ Date and time entries. ▪ Provide objective, factual, and complete documentation. ▪ Document care, medications, treatments, and procedures as soon as possible after completion. ▪ Document client responses to interventions. ▪ Document consent for or refusal of treatments. ▪ Document calls made to other health care providers. ▪ Use quotes as appropriate for subjective data. ▪ Use correct spelling, grammar, and punctuation. ▪ Sign and title each entry. ▪ Follow agency policies when an error is made (i.e., draw 1 line through the error, initial, and date). ▪ Follow agency guidelines regarding late entries. ▪ Use only the user identification code, name, or password for computerized documentation. ▪ Maintain privacy and confidentiality of documented infor- mation printed from the computer. ▪ Do not document for others or change documentation for other individuals. ▪ Do not use unacceptable abbreviations. ▪ Do not use judgmental or evaluative statements, such as “uncooperative client.” ▪ Do not leave blank spaces on documentation forms. ▪ Do not lend access identification computer codes to another person; change password at regular intervals. 53 CHAPTER 6 Ethical and Legal Issues
- 72. F u n d a m e n t a l s 2. The nurse needs to ensure that the client has been provided with information about the right to identify written directions about the care that the client wishes to receive. 3. On admission to a health care facility, the nurse determines whether an advance directive exists and ensures that it is part of the medical record; the nurse also offers information about advance directives if the client indicates he or she wants more information. 4. The nurse ensures that the HCP is aware of the presence of an advance directive. 5. All health care workers need to follow the direc- tions of an advance directive to be safe from liability. 6. Some agencies have specific policies that pro- hibit the nurse from signing as a witness to a legal document, such as an instructional directive. 7. If allowed by the agency, when the nurse acts as a witness to a legal document, the nurse must docu- ment the event and the factual circumstances sur- rounding the signing in the medical record; documentation as a witness should include who was present, any significant comments by the cli- ent, and the nurse’s observations of the client’s conduct during this process. XII.Reporting Responsibilities A. Nurses are required to report certain communicable diseases or criminal activities such as child or elder abuse or domestic violence; dog bite or other animal bite, gunshot or stab wounds, assaults, and homicides; and suicides to the appropriate authorities. B. Impaired nurse 1. If the nurse suspects that a co-worker is abusing chemicals and potentially jeopardizing a client’s safety, the nurse must report the individual to the nursing supervisor/nursing administration in a confidential manner. (Client safety is always the first priority.) 2. Nursing administration notifies the board of nursing regarding the nurse’s behavior. 3. Many institutions have policies that allow for drug testing if impairment is suspected. C. Occupational Safety and Health Act (OSHA) 1. OSHA requires that an employer provide a safe workplace for employees accordingto regulations. 2. Employees can confidentially report working conditions that violate regulations. 3. An employee who reports unsafe working condi- tions cannot be retaliated against by the employer. D. Sexual harassment 1. Sexual harassment is prohibited by state and federal laws. 2. Sexual harassment includes unwelcome conduct of a sexual nature. 3. Follow agency policies and procedures to handle reporting a concern or complaint. CRITICALTHINK ING W hat Should Y ou Do? Answer: If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client’s request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client’s request so that the surgeon can discuss the conse- quences of not having the surgery with the client. Under no circumstances would the nurse continue with surgical preparation if the client has indicated that he or she does not want the surgery. Further assessment and follow-up related to the client’s request need to be done. In addition, it is the client’s right to refuse treatment. References: Lewis et al. (2014), p. 326. Perry, Potter, Ostendorf (2014), p. 882. P RAC TI CE Q U ES TI O N S 13. The nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and com- pletes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed. 14. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multi- ple fractures and is unconscious. An emergency cra- niotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family. 15. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not 54 UNIT II Professional Standards in Nursing
- 73. injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse’s notes that an incident report was completed. 4. Contact the nursing supervisor to update infor- mation regarding the fall. 16. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. Refuse to float to the ICU based on lack of unit orientation. 2. Clarify with the team leader to make a safe ICU client assignment. 3. Ask the nursing supervisor to review the hospital policy on floating. 4. Submit a written protest to nursing administra- tion, and then call the hospital lawyer. 17. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourni- quet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe contain- ing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained. 18. A hospitalized client tells the nurse that an instruc- tional directive is being prepared and that the lawyer will be bringing the document to the hos- pital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. “I will sign as a witness to your signature.” 2. “You will need to find a witness on your own.” 3. “Whoever is available at the time will sign as a witness for you.” 4. “I will call the nursing supervisor to seek assis- tance regarding your request.” 19. The nurse has made an error in a narrative docu- mentation of an assessment finding on a client and obtains the client’s record to correct the error. The nurse should take which actions to correct the error? Select all that apply. 1. Document a late entry in the client’s record. 2. Draw 1 line through the error, initialing and dating it. 3. Try to erase the error for space to write in the correct data. 4. Use whiteout to delete the error to write in the correct data. 5. Write a concise statement to explain why the correction was needed. 6. Document the correct information and end with the nurse’s signature and title. 20. Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client’s left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 21. Anursing instructor delivers a lecture to nursing stu- dents regarding the issue of client’s rights and asks a nursing student to identify a situation that repre- sents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client’s permission 22. Nursingstaffmembers are sitting in the lounge taking their morning break. An unlicensed assistive person- nel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? 1. Libel 2. Slander 3. Assault 4. Negligence 23. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confi- dence that her son frequently hits her if supper is not prepared on time when he arrives home from F u n d a m e n t a l s 55 CHAPTER 6 Ethical and Legal Issues
- 74. work. Which is the most appropriate nursing response? 1. “Oh, really? I will discuss this situation with your son.” 2. “Let’s talk about the ways you can manage your time to prevent this from happening.” 3. “Do you have any friends who can help you out until you resolve these important issues with your son?” 4. “As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay.” 24. The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recom- mended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the HCP can be contacted. 4. Administer the recommended dose until the HCP can be located. 25. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexu- ally oriented photograph. Which is the most appro- priate initial nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursingsupervisor and report the incident. 4. Call the laboratory and ask for the name of the individual who sent the photograph. AN S WERS 13. 3 Rationale: The incident report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse. Test-Taking Strategy: Focus on the subject, documentation of events, and note the data in the question to select the correct option. Remember to focus on factual information when doc- umenting, and avoid including interpretations. This will direct you to the correct option. Review: Documentation principles related to incident reports Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Communication; Health Care Law Reference: Huber (2014), pp. 318–319. 14. 3 Rationale: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treat- ment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment. Test-Taking Strategy: Note the strategic word, best. Recalling that when an emergency is present and a delay in treatment for the purpose of obtaining informed consent could result in injury or death will direct you to the correct option. Review: The issues surrounding informed consent Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Ethics; Health Care Law References: Potter et al. (2013), pp. 302–303; Zerwekh, Zer- wekh Garneau (2015), pp. 475–476. 15. 1 Rationale: After a client’s fall, the nurse must frequently reas- sess the client because potential complications do not always appear immediately after the fall. The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only the individuals participating in the client’s care. An incident report is a problem-solving document; however, its comple- tion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary. Test-Taking Strategy: Note the strategic word, next. Using the steps of the nursing process will direct you to the correct option. Remember that assessment is the first step. Addition- ally, use Maslow’s Hierarchy of Needs theory, recalling that physiological needs are the priority. The correct option is the only option that addresses a potential physiological need of the client. Review: Guidelines related to incident reports and care to the client after sustaining a fall Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Communication; Safety References: Lewis et al. (2014), p. 1682; Zerwekh, Zerwekh Garneau (2015), pp. 479–480. F u n d a m e n t a l s 56 UNIT II Professional Standards in Nursing
- 75. 16. 2 Rationale: Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing super- visor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action. Test-Taking Strategy: Note the strategic word, best. Eliminate option 1 first because of the word refuse. Next, eliminate options 3 and 4 because they are premature actions. Review: Nursing responsibilities related to floating Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Care Coordination; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 589–591. 17. 3 Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervi- sion of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action. Test-Taking Strategy: Note the strategic words, most appro- priate. Eliminate option 4 first because this is an inappropriate and unsafe action. Recall the lines of organizational structure to assist in directing you to the correct option. Review: The nurse’s responsibilities when dealing with an impaired nurse Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Ethics; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 452–453. 18. 4 Rationale: Instructional directives (living wills) are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor. Test-Taking Strategy: Note the strategic words, most appropri- ate. Options 1 and 3 are comparable or alike and should be eliminated first. Option 2 is eliminated because it is a nonther- apeutic response. Review: Legal implications associated with instructional directives Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Health Care Law; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 420, 476–477. 19. 2, 6 Rationale: If the nurse makes an error in narrative documen- tation in the client’s record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then doc- umenting the correct information. A late entry is used to document additional information not remembered at the ini- tial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse’s signature and title is correct. Erasing data from the client’s record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary. Test-Taking Strategy: Focus on the subject, correcting a doc- umentation error, and use principles related to documenta- tion. Recalling that alterations to a client’s record are to be avoided will assist in eliminating options 3 and 4. From the remaining options, focusing on the subject of the question and using knowledge regarding the principles related to docu- mentation will direct you to the correct option. Review: The principles and guidelines related to documen- tation Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Communication; Professionalism References: Perry, Potter, Ostendorf (2014), p. 51; Zerwekh, Zerwekh Garneau (2015), p. 466. 20. 1, 2, 5 Rationale: Factual documentation contains descriptive, objec- tive information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion. Test-Taking Strategy: Focus on the subject, accurate docu- mentation notations. Eliminate options 3 and 4 because they are comparable or alike and include vague terms (seemed, appears). Review: Documentation guidelines Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Communication; Professionalism Reference: Perry, Potter, Ostendorf (2014), pp. 50–51. F u n d a m e n t a l s 57 CHAPTER 6 Ethical and Legal Issues
- 76. 21. 4 Rationale: Invasion of privacy occurs with unreasonable intru- sion into an individual’s private affairs. Performing a proce- dure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the cli- ent that the client cannot leave the hospital constitutes false imprisonment. Test-Taking Strategy: Focus on the subject, invasion of privacy. Noting the words without the client’s permission will direct you to this option. Review: Situations that include invasion of privacy Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Ethics; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 447, 473– 474. 22. 2 Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s repu- tation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of profes- sionals that fall below the standard of care for a specific professional group. Test-Taking Strategy: Note the subject, the legal tort violated. Focus on the data in the question and eliminate options 3 and 4 first because their definitions are unrelated to the data. Recalling that slander constitutes verbal defamation will direct you to the correct option from the remaining options. Review: The definitions of libel, slander, assault, and negligence Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Health Care Law; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 448, 473. 23. 4 Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and cer- tain infectious diseases. Confidential issues are not to be dis- cussed with nonmedical personnel or the client’s family or friends without the client’s permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client. Test-Taking Strategy: Note the strategic words, most appropri- ate. Focus on the data in the question and note that an 87- year-old woman is receiving physical abuse by her son. Recall the nursing responsibilities related to client safety and report- ing obligations. Options 1, 2, and 3 should be eliminated because they are comparable or alike in that they do not pro- tect the client from injury. Review: The nursing responsibilities related to reporting responsibilities Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Health Care Law; Interpersonal Violence References: Lewis et al. (2014), pp. 68–69; Zerwekh, Zerwekh Garneau (2015), p. 472. 24. 1 Rationale: If the HCP writes a prescription that requires clari- fication, the nurse’s responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no cir- cumstances should the nurse proceed to carry out the prescrip- tion until obtaining clarification. Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike and are unsafe actions. Holding the medication can result in client injury. The nurse needs to take action. The correct option clearly identifies the required action in this situation. Review: Nursing responsibilities related to the HCP’s prescriptions Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), p. 489. 25. 3 Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harass- ment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these con- cerns should be reported to the nursing supervisor immedi- ately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions. Test-Taking Strategy: Note the strategic words, most appropri- ate initial. Remember that using the organizational channels of communication is best. This will assist in directing you to the correct option. Review: Nursing responsibilities when sexual harassment occurs in the workplace Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Health Care Law; Professionalism Reference: Zerwekh, Zerwekh Garneau (2015), pp. 474–475. F u n d a m e n t a l s 58 UNIT II Professional Standards in Nursing
- 77. F u n d a m e n t a l s CH AP TER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning PRIORITYCONCEPTS Leadership; Health Care Organizations CRITICALTHINK ING W hat Should Y ou Do? The nurse notes that there has been an increase in the number ofintravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program? Answer located on p. 71. I. Health Care Delivery Systems A. Managed care 1. Managed care is a broad term used to describe strategies used in the health care delivery system that reduce the costs of health care. 2. Client care is outcome driven and is managed by a case management process. 3. Managed care emphasizes the promotion of health, client education and responsible self- care, early identification of disease, and the use of health care resources. B. Case management 1. Case management is a health care delivery strat- egy that supports managed care; it uses an inter- professional health care delivery approach that provides comprehensive client care throughout the client’s illness, using available resources to promote high-quality and cost-effective care. 2. Case management includes assessment and development of a plan of care, coordination of all services, referral, and follow-up. 3. Critical pathways are used, and variation analysis is conducted. Case management involves consultation and collab- oration with an interprofessional health care team. C. Case manager 1. A case manager is a professional nurse who assumes responsibility for coordinating the cli- ent’s care at admission and after discharge. 2. The case manager establishes a plan of care with the client, coordinates any interprofessional consultations and referrals, and facilitates discharge. D. Critical pathway 1. A critical pathway is a clinical management care plan for providing client-centered care and for planning and monitoring the client’s progress within an established time frame; interprofes- sional collaboration and teamwork ensure shared decision making and quality client care. 2. Variation analysis is a continuous process that the case manager and other caregivers conduct by comparing the specific client outcomes with the expected outcomes described on the critical pathway. 3. The goal of a critical pathway is to anticipate and recognize negative variance (i.e., client prob- lems) early so that appropriate action can be taken and positive client outcomes can result. E. Nursing care plan 1. A nursing care plan is a written guideline and communication tool that identifies the client’s pertinent assessment data, problems and nursing diagnoses, goals, interventions, and expected outcomes. 2. The plan enhances interprofessional continuity of care by identifying specific nursing actions necessary to achieve the goals of care. 3. The client and family are involved in developing the plan of care, and the plan identifies short- term and long-term goals. 59
- 78. 4. Client problems, goals, interventions, and expected outcomes are documented in the care plan, which provides a framework for evaluation of the client’s response to nursing actions. II. Nursing Delivery Systems A. Functional nursing 1. Functional nursing involves a task approach to client care, with tasks being delegated by the charge nurse to individual members of the team. 2. This type of system is task-oriented, and the team member focuses on the delegated task rather than the total client; this results in fragmentation of care and lack of accountability by the team member. B. Team nursing 1. The team generally is led by a registered nurse (team leader) who is responsible for assessing cli- ents, analyzing client data, planning, and evalu- ating each client’s plan of care. 2. The team leader determines the work assign- ment; each staff member works fully within the realm of his or her educational and clinical expertise and job description. 3. Each staff member is accountable for client care and outcomes of care delivered in accordance with the licensing and practice scope as deter- mined by health care agency policy and state law. 4. Modular nursing is similar to team nursing, but takes into account the structure of the unit; the unit is divided into modules, allowing nurses to care for a group of clients who are geographi- cally close by. C. Relationship-based practice (primary nursing) 1. Relationship-based practice (primary nursing) is concerned with keeping the nurse at the bedside, actively involved in client care, while planning goal-directed, individualized care. 2. One (primary) nurse is responsible for managing and coordinating the client’s care while in the hospital and for discharge, and an associate nurse cares for the client when the primary nurse is off-duty. D. Client-focused care 1. This is also known as the total care or case method; the registered nurse assumes total responsibility for planning and delivering care to a client. 2. The client may have different nurses assigned dur- ing a 24-hour period; the nurse provides all neces- sary care needed for the assigned time period. III. Professional Responsibilities A. Accountability 1. The process in which individuals have an obliga- tion (or duty) to act and are answerable for their actions. 2. Involves assuming only the responsibilities that are within one’s scope of practice and not assum- ing responsibility for activities in which compe- tence has not been achieved. 3. Involves admitting mistakes rather than blaming others and evaluating the outcomes of one’s own actions. 4. Includes a responsibility to the client to be com- petent, providing nursing care in accordance with standards of nursing practice and adhering to the professional ethics codes. Accountabilityis the acceptance ofresponsibilityfor one’s actions. The nurse is always responsible for his or her actions when providing care to a client. B. Leadership and management 1. Leadership is the interpersonal process that involves influencing others (followers) to achieve goals. 2. Management is the accomplishment of tasks or goals by oneself or by directing others. C. Theories of leadership and management (Box 7-1) D. Leader and manager approaches 1. Autocratic a. The leader or manager is focused and main- tains strong control, makes decisions, and addresses all problems. b. The leader or manager dominates the group and commands rather than seeks suggestions or input. 2. Democratic a. This is also called participative management. b. It is based on the belief that every group mem- ber should have input into problem solving and the development of goals; leader obtains participation from group and them makes best decision for the organization, based upon the input from group. F u n d a m e n t a l s BOX 7-1 Theories of Leadership and Management Charismatic: Based on personal beliefs and characteristics Quantum: Based on the concepts of chaos theory; maintain- ing a balance between tension and order prevents an unstable environment and promotes creativity Relational: Based on collaboration and teamwork Servant: Based on a desire to serve others; the leader emerges when another’s needs assume priority Shared: Based on the belief that several individuals share the responsibility for achieving the health care agency’s goals Transactional: Based on the principles of social exchange theory Transformational: Based on the individual’s commitment to the health care agency’s vision; focuses on promoting change 60 UNIT II Professional Standards in Nursing
- 79. c. The democratic style is a more “talk with the members” style and much less authoritarian than the autocratic style. 3. Laissez-faire a. A laissez-faire leader or manager assumes a passive, nondirective, and inactive approach and relinquishes part or all of the responsibil- ities to the members of the group. b. Decision making is left to the group, with the laissez-faire leader or manager providing lit- tle, if any, guidance, support, or feedback. 4. Situational a. Situational style uses a combination of styles based on the current circumstances and events. b. Situational styles are assumed according to the needs of the group and the tasks to be achieved. 5. Bureaucratic a. The leader or manager believes that individ- uals are motivated by external forces. b. The leader or manager relies on organiza- tional policies and procedures for decision making. E. Effective leader and manager behaviors and qualities (Box 7-2) F. Functions of management (Box 7-3) G. Problem-solving process and decision making 1. Problem solving involves obtaining information and using it to reach an acceptable solution to a problem. 2. Decision making involves identifying a problem and deciding which alternatives can best achieve objectives. 3. Steps of the problem-solving process are similar to the steps of the nursing process (Table 7-1). H. Types of managers 1. Frontline manager a. Frontline managers function in supervisory roles of those involved with delivery of client care. b. Frontline roles usually include charge nurse, team leader, and client care coordinator. c. Frontline managers coordinate the activity of all staff who provide client care and supervise team members during the manager’s period of accountability. 2. Middle manager a. Middle manager roles usually include unit manager and supervisor. b. A middle manager’s responsibilities may include supervising staff, preparing budgets, preparing work schedules, writing and imple- menting policies that guide client care and unit operations, and maintaining the quality of client services. 3. Nurse executive a. The nurse executive is a top-level nurse man- ager and may be the director of nursing ser- vices or the vice president for client care services. F u n d a m e n t a l s BOX7-2 Effective Leader and Manager Behaviors and Qualities Behaviors Treats employees as unique individuals Inspires employees and stimulates critical thinking Shows employees how to think about old problems in new ways and assists with adapting to change Is visible to employees; is flexible; and provides guidance, assistance, and feedback Communicates a vision, establishes trust, and empowers employees Motivates employees to achieve goals Qualities Effective communicator; promotes interprofessional collabo- ration Credible Critical thinker Initiator of action Risk taker Is persuasive and influences employees Adapted from Huber D: Leadership and nursing care management, ed 5, Philadelphia, 2014, Saunders. BOX 7-3 Functions of Management Planning: Determining objectives and identifying methods that lead to achievement of objectives Organizing: Using resources (human and material) to achieve predetermined outcomes Directing: Guiding and motivating others to meet expected outcomes Controlling: Using performance standards as criteria for mea- suring success and taking corrective action TABLE 7-1 Similarities of the Problem-Solving Process and the Nursing Process Problem-Solving Process Nursing Process Identifying a problem and collecting data about the problem Assessment Determining the exact nature of the problem Analysis Deciding on a plan of action Planning Carrying out the plan Implementation Evaluating the plan Evaluation 61 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 80. b. The nurse executive supervises numerous departments and works closely with the administrative team of the organization. c. The nurse executive ensures that all client care provided by nurses is consistent with the objectives of the health care organization. IV. Power A. Power is the ability to do or act to achieve desired results. B. Powerful people are able to modify behavior and influence others to change, even when others are resistant to change. C. Effective nurse leaders use power to improve the delivery of care and to enhance the profession. D. There are different types of power (Box 7-4). V. Empowerment A. Empowerment is an interpersonal process of enabling others to do for themselves. B. Empowerment occurs when individuals are able to influence what happens to them more effectively. C. Empowerment involves open communication, mutual goal setting, and decision making. D. Nurses can empower clients through teaching and advocacy. VI. Formal Organizations A. An organization’s mission statement communicates in broad terms its reason for existence; the geograph- ical area that the organization serves; and attitudes, beliefs, and values from which the organization functions. B. Goals and objectives are measurable activities spe- cific to the development of designated services and programs of an organization. C. The organizational chart depicts and communicates how activities are arranged, how authority relation- ships are defined, and how communication chan- nels are established. D. Policies, procedures, and protocols 1. Policies are guidelines that define the organiza- tion’s standpoint on courses of action. 2. Procedures are based on policy and define methods for tasks. 3. Protocols prescribe a specific course of action for a specific type of client or problem. a. Centralization is the making of decisions by a few individuals at the top of the organization or by managers of a department or unit, and decisions are communicated thereafter to the employees. b. Decentralization is the distribution of author- ity throughout the organization to allow for increased responsibility and delegation in decision making; decentralization tries to move the decision-making as close to the client as possible. The nurse must follow policies, procedures, and protocols of the health care agency in which he or she is employed. VII. Evidence-Based Practice A. Research is an important role of the professional nurse. Research provides a foundation for improve- ment in nursing practice. B. Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. C. Determining the client’s personal, social, cultural, and religious preferences ensures individualization and is a component of implementing evidence- based practice. D. The nurse needs to be an observer and identify and question situations that require change or result in a less than desirable outcome. E. Use of information technology such as online resources, including research publications, provides current research findings related to areas of practice. F. The nurse needs to follow evidence-based practice protocols developed by the institution and question the rationale for nursing approaches identified in the protocols as necessary. The nurse should use appro- priate evaluation criteria when determining areas in need of research (Table 7-2). Evidence-based practice requires that the nurse base nursing practice on the best and most applicable evidence from clinical research studies. The nurse should also be alert to clinical issues that warrant inves- tigation and develop a researchable problem about the issue. VIII. Quality Improvement A. Also known as performance improvement, quality improvement focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor F u n d a m e n t a l s BOX 7-4 Types of Power Reward: Ability to provide incentives Coercive: Ability to punish Referent: Based on attraction Expert: Based on having an expert knowledge foundation and skill level Legitimate: Based on a position in society Personal: Derived from a high degree of self-confidence Informational: When one person provides explanations why another should behave in a certain way 62 UNIT II Professional Standards in Nursing
- 81. outcomes of care and to determine the need for change to improve the quality of care. B. Quality improvement processes or systems may be named quality assurance, continuous quality management, or continuous quality improvement. C. When quality improvement is part of the philosophy of a health care agency, every staff member becomes involved in ways to improve client care and outcomes. D. A retrospective (“looking back”) audit is an evalua- tion method used to inspect the medical record after the client’s discharge for documentation of compli- ance with the standards. E. A concurrent (“at the same time”) audit is an evalu- ation method used to inspect compliance of nurses with predetermined standards and criteria while the nurses are providing care during the client’s stay. F. Peer review is a process in which nurses employed in an organization evaluate the quality of nursing care delivered to the client. G. The quality improvement process is similar to the nursing process and involves an interprofessional approach. H. An outcome describes the most positive response to care;comparison ofclient responses with the expected outcomes indicates whether the interventions are effective, whether the client has progressed, how well standards are met, and whether changes are necessary. I. The nurse is responsible for recognizingtrends in nurs- ing practice, identifying recurrent problems, and initi- ating opportunities to improve the quality of care. Qualityimprovement processes improve the quality of care delivery to clients and the safety of health care agencies. IX. Change Process A. Change is a dynamic process that leads to an alter- ation in behavior. 1. Lewin’s basic concept of the change process includes 3 elements for successful change: unfreezing, moving and changing, and refreezing (Fig. 7-1). a. Unfreezing is the first phase of the process, during which the problem is identified and individuals involved gather facts and evi- dence supporting a basis for change. b. During the moving and changing phase, change is planned and implemented. c. Refreezing is the last phase of the process, during which the change becomes stabilized. 2. Leadership style influences the approach to initi- ating the change process. B. Types of change 1. Planned change: Adeliberate effort to improve a situation 2. Unplanned change: Change that is unpredictable but is beneficial and may go unnoticed C. Resistance to change (Box 7-5) 1. Resistance to change occurs when an individual rejects proposed new ideas without critically thinking about the proposal. 2. Change requires energy. 3. The change process does not guarantee positive outcomes. D. Overcoming barriers 1. Create a flexible and adaptable environment. 2. Encourage the people involved to plan and set goals for change. 3. Include all involved in the plan for change. 4. Focus on the benefits of the change in relation to improvement of client care. 5. Delineate the drawbacks from failing to make the change in relation to client care. 6. Evaluate the change process on an ongoing basis, and keep everyone informed of progress. 7. Provide positive feedback to all involved. 8. Commit to the time it takes to change. F u n d a m e n t a l s TABLE 7-2 Evaluation Criteria for Evidence for Clinical Questions Level Definition Level I Evidence comes from a review of a number of randomized controlled trials (RCTs) or from clinical practice guidelines that are based on such a review. Level II Evidence comes from at least one well-designed RCT. Level III Evidence comes from well-designed controlled studies that are not randomized. Level IV Evidence comes from well-designed case-controlled and cohort studies. Level V Evidence comes from a number of descriptive or qualitative studies. Level VI Evidence comes from a single descriptive or qualitative study. Level VII Evidence comes from the opinion of authorities and/or reports of expert committees. From Zerwekh J, Zerwekh Garneau A: Nursing today: transition and trends, ed 8, Philadelphia, 2015, Saunders. Data from Sackett D et al.: Evidence-based medicine: how to practice and teach EBM, London, 2000, Churchill Livingstone. Unfreezin g R e f r e e z i n g Moving/Chan g i n g FIGURE 7-1 Elements of a successful change. 63 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 82. F u n d a m e n t a l s X. Conflict A. Conflict arises from a perception of incompatibility or difference in beliefs, attitudes, values, goals, prior- ities, or decisions. B. Types of conflict 1. Intrapersonal: Occurs within a person 2. Interpersonal: Occurs between and among cli- ents, nurses, or other staff members 3. Organizational: Occurs when an employee con- fronts the policies and procedures of the organization C. Modes of conflict resolution 1. Avoidance a. Avoiders are unassertive and uncooperative. b. Avoiders do not pursue their own needs, goals, or concerns, and they do not assist others to pursue theirs. c. Avoiders postpone dealing with the issue. 2. Accommodation a. Accommodators neglect their own needs, goals, or concerns (unassertive) while trying to satisfy those of others. b. Accommodators obey and serve others and often feel resentment and disappointment because they “get nothing in return.” 3. Competition a. Competitors pursue their own needs and goals at the expense of others. b. Competitors also may stand up for rights and defend important principles. 4. Compromise a. Compromisers are assertive and cooperative. b. Compromisers work creatively and openly to find the solution that most fully satisfies all important goals and concerns to be achieved. XI. Roles of Health Care Team Members A. Nurse roles are as follows: 1. Promote health and prevent disease 2. Provide comfort and care to clients 3. Make decisions 4. Act as client advocate 5. Lead and manage the nursing team 6. Serve as case manager 7. Function as a rehabilitator 8. Communicate effectively 9. Educate clients, families, and communities and health care team members 10. Act as a resource person 11. Allocate resources in a cost-effective manner B. Health care provider (HCP): An HCP diagnoses and treats disease. C. HCP assistant 1. An HCP assistant (also known as physician assis- tant) acts to a limited extent in the role of the HCP during the HCP’s absence. 2. The HCP assistant conducts physical examina- tions, performs diagnostic procedures, assists in the operating room and emergency department, and performs treatments. 3. Certified and licensed HCP assistants in some states have prescriptive powers. D. Nurse practitioner: an advanced practice registered nurse (APRN) who is educated to diagnose and treat acute illness and chronic conditions; health promo- tion and maintenance is a focus. E. Physical therapist: A physical therapist assists in examining, testing, and treating physically disabled clients. F. Occupational therapist: An occupational therapist develops adaptive devices that help chronically ill or handicapped clients to perform activities of daily living. G. Respiratory therapist: Arespiratory therapist delivers treatments designed to improve the client’s ventila- tion and oxygenation status. H. Speech therapist: A speech therapist evaluates a cli- ent’s ability to swallow safely and effectively and communicates a plan to improve a client’s swallow- ing ability. I. Nutritionist: A nutritionist or dietitian assists in planning dietary measures to improve or maintain a client’s nutritional status. J. Continuing care nurse: This nurse coordinates dis- charge plans for the client. K. Assistive personnel, including unlicensed assistive personnel and client care technicians, help the regis- tered nurse with specified tasks and functions. L. Pharmacist: A pharmacist formulates and dispenses medications. M. Social worker: A social worker counsels clients and families about home care services and assists the con- tinuing care nurse with planning discharge. BOX 7-5 Reasons for Resisting Change Conformity One goes along with others to avoid conflict. Dissimilar Beliefs and Values Differences can impede positive change. Habit Routine, set behaviors are often hard to change. Secondary Gains Benefits or payoff are present, so there is no incentive to change. Threats to Satisfying Basic Needs Change may be perceived as a threat to self-esteem, security, or survival. Fear One fears failure or has fear of the unknown. 64 UNIT II Professional Standards in Nursing
- 83. N. Chaplain: A chaplain (or trained layperson) offers spiritual support and guidance to clients and families. O. Administrative staff: Administrative or support staff members organize and schedule diagnostic tests and procedures and arrange for services needed by the client and family. XII. Interprofessional Collaboration A. Client care planning can be accomplished through referrals to or consultations or interprofessional col- laborations with other health care specialists and through client care conferences, which involve mem- bers from all health care disciplines. This approach helps to ensure continuity of care. B. Reports 1. Reports should be factual, accurate, current, complete, and organized. 2. Reports should include essential background information, subjective data, objective data, any changes in the client’s status, client problems or nursing diagnoses as appropriate, treatments and procedures, medication administration, cli- ent teaching, discharge planning, family infor- mation, the client’s response to treatments and procedures, and the client’s priority needs. 3. Change of shift report a. The report facilitates continuity of care among nurses who are responsible for a client. b. The report may be written, oral, audiotaped, or provided during walking rounds at the cli- ent’s bedside. c. The report describes the client’s health status and informs the nurse on the next shift about the client’s needs and priorities for care. 4. Telephone reports a. Purposes include informing an HCP of a cli- ent’s change in status, communicating infor- mation about a client’s transfer to or from another unit or facility, and obtaining results of laboratory or diagnostic tests. b. The telephone report should be documented and should include when the call was made, who made the call, who was called, to whom information was given, what information was given, and what information was received. 5. Transfer reports a. Transferring nurse reports provide continuity of care and may be given by telephone or in person (Box 7-6). b. Receiving nurse should repeat transfer infor- mation to ensure client safety and ask ques- tions to clarify information about the client’s status. 6. Situation, Background, Assessment, Recommen- dation (SBAR) a. SBAR is a structured and standardized com- munication technique that improves com- munication among team members when sharing information on a client. b. SBAR includes up-to-date information about the client’s situation, associated background information, assessment data, and recom- mendations for care, such as treatments, med- ications, or services needed. XIII. Interprofessional Consultation A. Consultation is a process in which a specialist is sought to identify methods of care or treatment plans to meet the needs of a client. B. Consultation is needed when the nurse encounters a problem that cannot be solved using nursing knowl- edge, skills, and available resources. C. Consultation also is needed when the exact problem remains unclear; a consultant can objectively and more clearly assess and identify the exact nature of the problem. D. Rapid response teams are being developed within hospitals to provide nursing staff with internal con- sultative services provided by expert clinicians. E. Rapid response teams are used to assist nursing staff with earlydetection and resolution ofclient problems. F. Medication reconciliation includes collaboration among the client, HCPs, nurses, and pharmacists to ensure medication accuracy when clients experi- ence changes in health care settings or levels of care or are transferred from one care unit to another, and upon discharge (Box 7-7). F u n d a m e n t a l s BOX 7-6 Transfer Reports ▪ Client’s name, age, health care provider, and diagnoses ▪ Current health status and plan of care ▪ Client’s needs and priorities for care ▪ Any assessments or interventions that need to be per- formed after transfer, such as laboratorytests, medication administration, or dressing changes ▪ Need for any special equipment ▪ Additional considerations such as allergies, resuscitation status, precautionary considerations, cultural or religious issues, or family issues BOX 7-7 Process for Medication Reconciliation 1. Obtain a list of current medications from the client. 2. Develop an accurate list of newly prescribed medications. 3. Compare newmedications to the list ofcurrent medications. 4. Identify and investigate any discrepancies and collaborate with the health care provider as necessary. 5. Communicate the finalized list with the client, caregivers, health care provider, and other team members. From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 65 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 84. F u n d a m e n t a l s XIV. Discharge Planning A. Discharge planning begins when the client is admit- ted to the hospital or health care facility. B. Discharge planningis an interprofessional process that ensures that the client has a plan for continuing care after leaving the health care facility and assists in the client’s transition from one environment to another. C. All caregivers need to be involved in discharge plan- ning, and referrals to other HCPs or agencies may be needed. An HCP’s prescription may be needed for the referral, and the referral needs to be approved by the client’s health care insurer. D. The nurse should anticipate the client’s discharge needs and make the referral as soon as possible (involving the client and family in the referral process). E. The nurse needs to educate the client and family regarding care at home (Box 7-8). XV. Delegation and Assignments A. Delegation 1. Delegation is a process of transferring perfor- mance of a selected nursing task in a situation to an individual who is competent to perform that specific task. 2. Delegation involves achieving outcomes and sharing activities with other individuals who have the authority to accomplish the task. 3. The nurse practice act and any practice limita- tions (institutional policies and procedures, and job descriptions of personnel provided by the institution) define which aspects of care can be delegated and which must be performed by a registered nurse. 4. Even though a task may be delegated to some- one, the nurse who delegates maintains account- ability for the task. 5. Only the task, not the ultimate accountability, may be delegated to another. 6. The 5 rights of delegation include the right task, right circumstances, right person, right direction/ communication, and right supervision/ evaluation. The nurse delegates onlytasks for which he or she is responsible. The nurse who delegates is accountable for the task; the person who assumes responsibility for the task is also accountable. B. Principles and guidelines of delegating (Box 7-9) C. Assignments 1. Assignment is the transfer of performance of cli- ent care activities to specific staff members. 2. Guidelines for client care assignments a. Always ensure client safety. b. Be aware of individual variations in work abilities. c. Determine which tasks can be delegated and to whom. d. Match the task to the delegatee on the basis of the nurse practice act and any practice limita- tions (institutional policies and procedures, and job descriptions of personnel provided by the institution). e. Provide directions that are clear, concise, accurate, and complete. f. Validate the delegatee’s understanding of the directions. g. Communicate a feeling of confidence to the delegatee, and provide feedback promptly after the task is performed. BOX 7-8 Discharge Teaching ▪ How to administer prescribed medications ▪ Side and adverse effects of medications that need to be reported to the health care provider (HCP) ▪ Prescribed dietary and activity measures ▪ Complications of the medical condition that need to be reported to the HCP ▪ How to perform prescribed treatments ▪ How to use special equipment prescribed for the client ▪ Schedule for home care services that are planned ▪ How to access available community resources ▪ When to obtain follow-up care BOX7-9 Principles and Guidelines of Delegating ▪ Delegate the right task to the right delegatee. Be familiar with the experience of the delegatees, their scopes of prac- tice, their job descriptions, agency policy and procedures, and the state nurse practice act. ▪ Provide clear directions about the task and ensure that the delegatee understands the expectations. ▪ Determine the degree of supervision that maybe required. ▪ Provide the delegatee with the authority to complete the task; provide a deadline for completion of the task. ▪ Evaluate the outcome of care that has been delegated. ▪ Provide feedback to the delegatee regarding his or her performance. ▪ In general, noninvasive interventions, such as skin care, range-of-motion exercises, ambulation, grooming, and hygiene measures, can be assigned to the unlicensed assistive personnel (UAP). ▪ In general, a licensed practical nurse (LPN) or licensed vocational nurse (LVN) can perform not onlythe tasks that a UAP can perform, but also certain invasive tasks, such as dressing changes, suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramus- cular, and selected piggyback medications), according to the education and job description of the LPN or LVN. The LPN or LVN can also review with the client teaching plans that were initiated by the registered nurse. ▪ A registered nurse can perform the tasks that an LPN or LVN can perform and is responsible for assessment and planning care, initiating teaching, and administering med- ications intravenously. 66 UNIT II Professional Standards in Nursing
- 85. h. Maintain continuity of care as much as possi- ble when assigning client care. XVI. Time Management A. Description 1. Time management is a technique designed to assist in completing tasks within a definite time period. 2. Learning how, when, and where to use one’s time and establishing personal goals and time frames are part of time management. 3. Time management requires an ability to antici- pate the day’s activities, to combine activities when possible, and to not be interrupted by non- essential activities. 4. Time management involves efficiency in com- pleting tasks as quickly as possible and effective- ness in deciding on the most important task to do (i.e., prioritizing) and doing it correctly. B. Principles and guidelines 1. Identify tasks, obligations, and activities and write them down. 2. Organize the workday; identify which tasks must be completed in specified time frames. 3. Prioritize client needs according to importance. 4. Anticipate the needs of the day and provide time for unexpected and unplanned tasks that may arise. 5. Focus on beginning the daily tasks, working on the most important first while keeping goals in mind; look at the final goal for the day, which helps in the breakdown of tasks into manageable parts. 6. Begin client rounds at the beginning of the shift, collecting data on each assigned client. 7. Delegate tasks when appropriate. 8. Keep a daily hour-by-hour log to assist in provid- ing structure to the tasks that must be accom- plished, and cross tasks off the list as they are accomplished. 9. Use health care agency resources wisely, antici- pating resource needs, and gather the necessary supplies before beginning the task. 10. Organize paperwork and continuously docu- ment task completion and necessary client data throughout the day (i.e., documentation should be concurrent with completion of a task or obser- vation of pertinent client data). 11. At the end of the day, evaluate the effectiveness of time management. XVII. Prioritizing Care A. Prioritizing is deciding which needs or problems require immediate action and which ones could tol- erate a delay in response until a later time because they are not urgent. B. Guidelines for prioritizing (Box 7-10) C. Setting priorities for client teaching 1. Determine the client’s immediate learning needs. 2. Review the learning objectives established for the client. 3. Determine what the client perceives as important. 4. Assess the client’s anxiety level and the time avail- able to teach. D. Prioritizing when caring for a group of clients 1. Identify the problems of each client. 2. Review the problems and any nursing diagnoses. 3. Determine which client problems are most urgent based on basic needs, the client’s chang- ing or unstable status, and complexity of the cli- ent’s problems. F u n d a m e n t a l s BOX 7-10 Guidelines for Prioritizing ▪ The nurse and the client mutuallyrank the client’s needs in order of importance based on the client’s preferences and expectations, safety, and physical and psychologicalneeds; what the client sees as his or her priorityneeds maybe dif- ferent from what the nurse sees as the priority needs. ▪ Priorities are classified as high, intermediate, or low. ▪ Client needs that are life-threatening or that could result in harm to the client if they are left untreated are high priorities. ▪ Nonemergency and non–life-threatening client needs are intermediate priorities. ▪ Client needs that are not related directly to the client’s ill- ness or prognosis are low priorities. ▪ When providing care, the nurse needs to decide which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. ▪ The nurse considers client problems that involve actual or life-threatening concerns before potential health- threatening concerns. ▪ When prioritizing care, the nurse must consider time con- straints and available resources. ▪ Problems identified as important by the client must be given high priority. ▪ The nurse can use the ABCs— airway–breathing–circula- tion— as a guide when determining priorities; client needs related to maintaining a patent airway are always the priority. ▪ If cardiopulmonary resuscitation (CPR) is necessary, the order of priority is CAB— compressions–airway–breath- ing— this is the exception to using the ABCs when determin- ing priorities. ▪ The nurse can use Maslow’s Hierarchy of Needs theory as a guide to determine priorities and to identify the levels of physiological needs, safety, love and belonging, self- esteem, and self-actualization (basic needs are met before moving to other needs in the hierarchy). ▪ The nurse can use the steps of the nursing process as a guide to determine priorities, remembering that assess- ment is the first step of the nursing process. 67 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 86. F u n d a m e n t a l s 4. Anticipate the time that it may take to care for the priority needs of the clients. 5. Combine activities, if possible, to resolve more than 1 problem at a time. 6. Involve the client in his or her care as much as possible (see Priority Nursing Actions). Use the ABCs (airway–breathing–circulation), Maslow’s Hierarchy of Needs theory, and the steps of the nursing process (assessment is first) to prioritize. Also consider the acuity level of clients when applying these guidelines. If cardiopulmonary resuscitation (CPR) needs to be initiated, use CAB (compressions– airway–breathing) as the priority guideline. XVIII. Disasters and Emergency Response Planning A. Description 1. A disaster is any human-made or natural event that causes destruction and devastation that can- not be alleviated without assistance (Box 7-11). 2. Internal disasters are disasters that occur within a health care agency (e.g., health care agency fire, structural collapse, radiation spill), whereas external disasters are disasters that occur outside the health care agency (e.g., mass transit accident that could send hundreds of victims to emer- gency departments). 3. Amulti-casualty event involves a limited number of victims or casualties and can be managed by a hospital with available resources; a mass casualty event involves a number of casualties that exceeds the resource capabilities of the hospital, and is also known as a disaster. 4. An emergency response plan is a formal plan of action for coordinating the response of the health care agency staff in the event of a disaster in the health care agency or surrounding community. B. American Red Cross (ARC) 1. The ARC has been given authority by the federal government to provide disaster relief. 2. All ARC disaster relief assistance is free, and local offices are located across the United States. 3. The ARC participates with the government in developing and testing community disaster plans. 4. The ARC identifies and trains personnel for emergency response. 5. The ARC works with businesses and labor orga- nizations to identify resources and individuals for disaster work. 6. The ARC educates the public about ways to pre- pare for a disaster. PRIORITYNURSING ACTIONS Assessing a Group of Clients in Order of Priority The nurse is assigned to the following clients. The order of priority in assessing the clients is as follows: 1. Aclient with heart failure who has a 4-lb weight gain since yesterday and is experiencing shortness of breath 2. A24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system 3. Aclient admitted to the hospital for observation who has absent bowel sounds 4. Aclient who is undergoing surgery for a hysterectomy on the following day The nurse determines the order of priorityby considering the needs ofthe client. The nurse also uses guidelines for pri- oritizing, such as the ABCs— airway–breathing–circulation— Maslow’s Hierarchy of Needs theory, and the steps of the nursing process. Clients 1 and 2 have conditions that relate to the cardiac system or respiratorysystem. These clients are the high priorities. Client 1is the first prioritybecause this cli- ent is experiencing shortness of breath (life-threatening). There is no indication that client 2 is experiencing any diffi- culty. Because client 4 is scheduled for surgeryon the follow- ing day, this client would be the last priority (low priority), and the nurse would assess this client and prepare this client for surgery after other clients are assessed. Because absent bowel sounds could be an indication of a bowel obstruction (intermediate priority), client 3 would be the nurse’s third priority. References Potter et al. (2013), pp. 237–238; Zerwekh, Zerwekh Garneau (2015), pp. 35–36. BOX 7-11 Types of Disasters Human-Made Disasters Dam failures resulting in flooding Hazardous substance accidents such as pollution, chemical spills, or toxic gas leaks Accidents involving release of radioactive material Resource shortages such as food, water, and electricity Structural collapse, fire, or explosions Terrorist attacks such as bombing, riots, and bioterrorism Mass transportation accidents Natural Disasters Avalanches Blizzards Communicable disease epidemics Cyclones Droughts Earthquakes Floods Forest fires Hailstorms Hurricanes Landslides Mudslides Tidal waves Tornadoes Volcanic eruptions 68 UNIT II Professional Standards in Nursing
- 87. F u n d a m e n t a l s 7. The ARC operates shelters, provides assistance to meet immediate emergency needs, and provides disaster health services, including crisis counseling. 8. The ARC handles inquiries from family members. 9. The ARC coordinates relief activities with other agencies. 10. Nurses are involved directly with the ARC and assume functions such as managers, supervisors, and educators of first aid; they also participate in emergency response plans and disaster relief pro- grams and provide services, such as blood collec- tion drives and immunization programs. C. HAZMAT (Hazardous Materials) Team 1. HAZMAT teams are typically composed of emer- gency department health care providers and nursing staff because they will be the first indi- viduals to encounter the potential exposure. 2. Members of HAZMAT teams have been educated on how to recognize patterns of illness that may be indicative of nuclear, biological, and chemical exposure; protocols for pharmacological treat- ment of infectious disease agents; availability of decontamination facilities and personal pro- tective gear; safety measures; and the methods of responding to an exposure. D. Phases of disaster management 1. The Federal Emergency Management Agency (FEMA) identifies 4 disaster management phases: mitigation, preparedness, response, and recovery. 2. Mitigation encompasses the following: a. Actions or measures that can prevent the occurrence of a disaster or reduce the damag- ing effects of a disaster b. Determination of the community hazards and community risks (actual and potential threats) before a disaster occurs c. Awareness of available community resources and community health personnel to facilitate mobilization of activities and minimize chaos and confusion if a disaster occurs d. Determination of the resources available for care to infants, older adults, disabled individ- uals, and individuals with chronic health problems 3. Preparedness encompasses the following: a. Plans for rescue, evacuation, and caring for disaster victims b. Plans for training disaster personnel and gathering resources, equipment, and other materials needed for dealing with the disaster c. Identification of specific responsibilities for various emergency response personnel d. Establishment of a community emergency response plan and an effective public com- munication system e. Development of an emergency medical sys- tem and a plan for activation f. Verification of proper functioning of emer- gency equipment g. Collection of anticipatory provisions and cre- ation of a location for providing food, water, clothing, shelter, other supplies, and needed medicine h. Inventory of supplies on a regular basis and replenishment of outdated supplies i. Practice of community emergency response plans (mock disaster drills) 4. Response encompasses the following: a. Putting disaster planning services into action and the actions taken to save lives and prevent further damage b. Primary concerns include safety, physical health, and mental health of victims and members of the disaster response team 5. Recovery encompasses the following: a. Actions taken to return to a normal situation after the disaster b. Preventing debilitating effects and restoring personal, economic, and environmental health and stability to the community E. Levels of disaster 1. FEMA identifies 3 levels of disaster with FEMA response (Box 7-12). 2. When a federal emergency has been declared, the federal response plan may take effect and activate emergency support functions. 3. The emergency support functions of the ARC include performing emergency first aid, shelter- ing, feeding, providing a disaster welfare infor- mation system, and coordinating bulk distribution of emergency relief supplies. 4. Disaster medical assistant teams (teams of spe- cially trained personnel) can be activated and sent to a disaster site to provide triage and medical care to victims until theycan be evacuated to a hospital. BOX 7-12 Federal Emergency Management Agency (FEMA) Levels of Disaster Level I Disaster Massive disaster that involves significant damage and results in a presidential disaster declaration, with major federal involvement and full engagement of federal, regional, and national resources Level II Disaster Moderate disaster that is likely to result in a presidential dec- laration of an emergency, with moderate federal assistance Level III Disaster Minor disaster that involves a minimal level of damage, but could result in a presidential declaration of an emergency 69 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 88. F u n d a m e n t a l s F. Nurse’s role in disaster planning 1. Personal and professional preparedness a. Make personal and family preparations (Box 7-13). b. Be aware of the disaster plan at the place of employment and in the community. c. Maintain certification in disaster training and in CPR. d. Participate in mock disaster drills, including a bomb threat drill. e. Prepare professional emergencyresponse items, such as a copy of nursing license, personal health care equipment such as a stethoscope, cash, warm clothing, record-keeping materials, and other nursing care supplies. 2. Disaster response a. In the health care agency setting, if a disaster occurs, the agency disaster preparedness plan (emergency response plan) is activated imme- diately, and the nurse responds by following the directions identified in the plan. b. In the community setting, if the nurse is the first responder to a disaster, the nurse cares for the victims by attending to the victims with life-threatening problems first; when res- cue workers arrive at the scene, immediate plans for triage should begin. In the event of a disaster, activate the emergency response plan immediately. G. Triage 1. In a disaster or war, triage consists of a brief assessment of victims that allows the nurse to classify victims according to the severity of the injury, urgency of treatment, and place for treat- ment (see Priority Nursing Actions). BOX 7-13 Emergency Plans and Supplies Plan a meeting place for family members. Identify where to go if an evacuation is necessary. Determine when and howto turn off water, gas, and electricity at main switches. Locate the safe spots in the home for each type of disaster. Replace stored water supply every 3 months and stored food supply every 6 months. Include the following supplies: ▪ Backpack, clean clothing, sturdy footwear ▪ Pocket-knife or multi-tool ▪ A 3-day supply of water (1 gallon per person per day) ▪ A 3-day supply of nonperishable food ▪ Blankets/sleeping bags/pillows ▪ First-aid kit with over-the-counter medications and vitamins ▪ Adequate supply of prescription medication ▪ Battery-operated radio ▪ Flashlight and batteries ▪ Credit card, cash, or traveler’s checks ▪ Personal ID card, list of emergency contacts, allergies, medical information, list of credit card numbers and bank accounts (all sealed in water-tight package) ▪ Extra set of car keys and a full tank of gas in the car ▪ Sanitation supplies for washing, toileting, and dispos- ing of trash; hand sanitizer ▪ Extra pair of eyeglasses/sunglasses ▪ Special items for infants, older adults, or disabled individuals ▪ Items needed for a pet such as food, water, and leash ▪ Paper, pens, pencils, maps ▪ Cell phone ▪ Work gloves ▪ Rain gear ▪ Roll of duct tape and plastic sheeting ▪ Radio and extra batteries ▪ Toiletries (basic daily needs, sunscreen, insect repel- lent, toilet paper) ▪ Plastic garbage bags and resealable bags ▪ Household bleach for disinfection ▪ Whistle ▪ Matches in a waterproof container From Ignatavicius D, Workman M: Medical surgical nursing: patient-centered collab- orative care, ed 7, Philadelphia, 2013, Saunders. PRIORITYNURSING ACTIONS Triaging Victims at the Site of an Accident The nurse is the first responder at the scene of a school bus accident. The nurse triages the victims from highest to low- est priority as follows: 1. Confused child with bright red blood pulsating from a leg wound 2. Child with a closed head wound and multiple compound fractures of the arms and legs 3. Child with a simple fracture of the arm complaining of arm pain 4. Sobbing child with several minor lacerations on the face, arms, and legs Triage systems identify which victims are the priority and should be treated first. Rankings are based on immediacy of needs, including victims with immediate threat to life requiring immediate treatment (emergent), victims whose injuries are not life-threatening provided that they are treated within 30 minutes to 2 hours (urgent), and victims with sustained local injuries who do not have immediate complications and can wait at least 2 hours for medical treatment (nonurgent). Victim 1 has a wound that is pulsating bright red blood; this indicates arterial puncture. The child is also confused, which indicates the presence ofhypoxia and shock(emergent). Victim 2 has sustained multiple traumas, so this victim is also classi- fied as emergent and would require immediate treatment;how- ever, victim 1 is the higher priority because of the arterial puncture. Victim 3 has sustained injuries that are not life- threatening provided that the injuries can be treated in 30 minutes to 2 hours (urgent). Victim 4 has sustained minor injuries that can wait at least 2hours for treatment (nonurgent). Reference Perry, Potter, Ostendorf (2014), pp. 327–328. 70 UNIT II Professional Standards in Nursing
- 89. F u n d a m e n t a l s 2. In an emergency department, triage consists of a brief assessment of clients that allows the nurse to classify clients according to their need for care and establish priorities of care; the type of illness or injury, the severity of the problem, and the resources available govern the process. H. Emergency department triage system 1. Acommonly used rating system in an emergency department is a 3-tier system that uses the catego- ries of emergent, urgent, and nonurgent; these categories may be identified by color coding or numbers (Box 7-14). 2. The nurse needs to be familiar with the triage sys- tem of the health care agency. 3. When caring for a client who has died, the nurse needs to recognize the importance of family and cultural and religious rituals and provide support to loved ones. 4. Organ donation procedures of the health care agency need to be addressed if appropriate. Think survivability. If you are the first responder to a scene ofa disaster, such as a train crash, a priorityvictim is one whose life can be saved. I. Client assessment in the emergency department 1. Primary assessment a. The purpose of primary assessment is to iden- tify any client problem that poses an immedi- ate or potential threat to life. b. The nurse gathers information primarily through objective data and, on finding any abnormalities, immediately initiates interventions. c. The nurse uses the ABCs—airway–breathing– circulation—as a guide in assessing a client’s needs and assesses a client who has sustained a traumatic injury for signs of a head injury or cervical spine injury. If CPR needs to be initiated, use CAB (compressions–airway– breathing) as the priority guideline. 2. Secondary assessment a. The nurse performs secondary assessment after the primary assessment and after treat- ment for any primary problems identified. b. Secondary assessment identifies any other life-threatening problems that a client might be experiencing. c. The nurse obtains subjective and objective data, including a history, general overview, vital sign measurements, neurological assess- ment, pain assessment, and complete or focused physical assessment. CRITICALTHINK ING W hat Should Y ou Do? Answer: Quality improvement, also known as performance improvement, focuses on processes or systems that signifi- cantly contribute to client safety and effective client care out- comes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed byevaluation of results based on the evidence-based practice protocols used. Reference: Zerwekh, Zerwekh Garneau (2015), pp. 511, 514. BOX 7-14 Emergency Department Triage Emergent (Red): Priority 1 (Highest) This classification is assigned to clients who have life- threatening injuries and need immediate attention and con- tinuous evaluation, but have a high probability for survival when stabilized. Such clients include trauma victims, clients with chest pain, clients with severe respiratorydistress or cardiac arrest, clients with limb amputation, clients with acute neurological deficits, and clients who have sustained chemical splashes to the eyes. Urgent (Yellow): Priority 2 This classification is assigned to clients who require treatment and whose injuries have complications that are not life- threatening, provided that they are treated within 30 minutes to 2 hours; these clients require continuous evaluation every 30 to 60 minutes thereafter. Such clients include clients with an open fracture with a distal pulse and large wounds. Nonurgent (Green): Priority 3 This classification is assigned to clients with local injuries who do not have immediate complications and who can wait at least 2 hours for medical treatment; these clients require eval- uation every 1 to 2 hours thereafter. Such clients include cli- ents with conditions such as a closed fracture, minor lacerations, sprains, strains, or contusions. Note: Some triage systems include tagging a client “Black” if the victim is dead or who soon will be deceased because of severe injuries; these are victims that would not benefit from any care because of the severity of injuries. From Ignatavicius D, Workman M: Medical surgical nursing: patient-centered collab- orative care, ed 7, Philadelphia, 2013, Saunders. 71 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 90. P RACTI CE Q U ES TI O N S 26. The nurse is assigned to care for four clients. In plan- ning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. Aclient scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift 27. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a head- ache, and history of seizures 2. A client who twisted her ankle when rollerblad- ing and is requesting medication for pain 3. A client with a minor laceration on the index fin- ger sustained while cutting an eggplant 4. Aclient with chest pain who states that he just ate pizza that was made with a very spicy sauce 28. Anursing graduate is attending an agency orientation regardingthe nursingmodel ofpractice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the cli- ent’s needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients. 29. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14Â109 /L) and a temperature of 38.4 °C 30. The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain med- ication was given to the client. 3. Ask the UAP to tell the client in pain that medica- tion will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 31. The nurse manager has implemented a change in the method of the nursing delivery system from func- tional to team nursing. An unlicensed assistive per- sonnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? 1. Ignore the resistance. 2. Exert coercion on the UAP. 3. Provide a positive reward system for the UAP. 4. Confront the UAP to encourage verbalization of feelings regarding the change. 32. The registered nurse is planning the client assign- ments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids 33. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hall- ways back into their rooms. 34. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing F u n d a m e n t a l s 72 UNIT II Professional Standards in Nursing
- 91. team. Which client would the nurse most appropri- ately assign to the licensed practical (vocational) nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours 35. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers’needs and abilities AN S WERS 26. 4 Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breath- ing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be iden- tified as intermediate priorities. Test-Taking Strategy: Note the strategic word, first. Use the ABCs—airway, breathing, and circulation—to answer the question. Remember that airway is always the highest priority. This will direct you to the correct option. Review: Prioritizing guidelines Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Prioritizing Priority Concepts: Care Coordination; Clinical Judgment References: Jarvis (2016), pp. 4–5; Potter et al. (2013), pp. 838–840. 27. 4 Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of ill- ness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple frac- ture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are clas- sified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as non- urgent and are a number-3 priority. Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to direct you to the correct option. A client experiencing chest pain is always classified as Priority 1 until a myocardial infarction has been ruled out. Review: The triage classification system Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Assessment Content Area: Leadership/Management—Triage Priority Concepts: Care Coordination; Clinical Judgment Reference: Jarvis (2016), pp. 4–5. 28. 4 Rationale: In team nursing, nursing personnel are led by a reg- istered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice). Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind and select the option that best describes a team approach. The correct option is the only one that identifies the concept of a team approach. Review: The various types of nursing delivery systems Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Delegating Priority Concepts: Care Coordination; Collaboration Reference: Huber (2014), pp. 263, 265–266. 29. 4 Rationale:Thenurseshould plan to carefortheclient who hasan elevated white blood cell count and a fever first because this cli- ent’s needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the post- operative client is best. Test-Taking Strategy: Note the strategic word, first, and use principles related to prioritizing. Recalling the normal white blood cell count is 5000–10,000 mm3 (5–10 Â 109 /L) and the normal temperature range 97.5 °F to 99.5 °F (36.4 °C to 37.5 °C) will direct you to the correct option. Review: The principles related to prioritizing guidelines Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Prioritizing Priority Concepts: Care Coordination; Clinical Judgment References: Potter et al. (2013), pp. 838–840; Zerwekh, Zer- wekh Garneau (2015), pp. 35–36. 30. 4 Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP. Test-Taking Strategy: Note the strategic words, most appropri- ate, and use principles related to priorities of care. Options 1 F u n d a m e n t a l s 73 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 92. and 3 are comparable or alike and delay the administration of pain medication, and option 2 is not a responsibility of the UAP. The most appropriate action is to plan to administer the medication. Review: Principles related to prioritizing care Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Prioritizing Priority Concepts: Care Coordination; Clinical Judgment Reference: Potter et al. (2013), p. 784. 31. 4 Rationale: Confrontation is an important strategy to meet resis- tance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of prob- lems and issues, and development ofstrategies to solve the prob- lem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a tempo- rary solution to the resistance, but will not address the concern specifically. Test-Taking Strategy: Note the strategic word, best. Options 1 and 2 can be eliminated first because of the words ignore in option 1 and coercion in option 2. From the remaining options, select the correct option over option 3 because the correct option specifically addresses problem-solving measures. Review: Resistance to change Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Ethical/Legal Priority Concepts: Leadership; Professionalism Reference: Huber (2014), pp. 38, 46–47. 32. 3 Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assign- ment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this proce- dure. Colostomy irrigations and tube feedings are not per- formed by UAPs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration. Test-Taking Strategy: Note the strategic words, most appropri- ate, and note the subject, an assignment to the UAP. Eliminate option 4 first because of the words difficulty swallowing. Next, eliminate options 1 and 2 because they are comparable or alike and are both invasive procedures and as such a UAP can- not perform these procedures. Review: Delegation guidelines Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Delegating Priority Concepts: Care Coordination; Clinical Judgment References: Huber (2014), pp. 147–148; Zerwekh, Zerwekh Garneau (2015), p. 305. 33. 2, 3, 4 Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client’s room and move beds away from windows, and close window shades and cur- tains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients con- fined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows. Test-Taking Strategy: Focus on the subject, protecting the cli- ent in the event of a tornado. Visualize each of the actions in the options to determine if these actions would assist in pro- tecting the client and preventing an accident or injury. Review: The various types of safety measures in the event of a disaster Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Leadership/Management—Prioritizing Priority Concepts: Leadership; Professionalism Reference: Potter et al. (2013), pp. 366–367, 387. 34. 4 Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambu- lation, and taking vital signs can be provided most appropri- ately by UAP. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. Test-Taking Strategy: Focus on the subject, assignment to a licensed practical (vocational) nurse, and note the strategic words, most appropriately. Recall that education and job posi- tion as described by the nurse practice act and employee guide- lines need to be considered when delegating activities and making assignments. Options 1, 2, and 3 can be eliminated because they are noninvasive tasks that the UAP can perform. Review: The principles and guidelines of delegation and assignments Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Delegating Priority Concepts: Care Coordination; Clinical Judgment Reference: Zerwekh, Zerwekh Garneau (2015), pp. 305, 308. 35. 1, 5 Rationale: There are guidelines that the nurse should use when delegatingand planningassignments. These include the follow- ing: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; vali- date the delegatee’s understanding of the directions; communi- cate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain F u n d a m e n t a l s 74 UNIT II Professional Standards in Nursing
- 93. continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guide- lines to use when delegating and planning assignments. Test-Taking Strategy: Focus on the subject, guidelines to use when delegating and planning assignments. Read each option carefully and use Maslow’s Hierarchy of Needs theory. Note that the correct options directly relate to the client’s needs and client safety. Review: The principles and guidelines of delegation and assignments. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Leadership/Management—Delegating Priority Concepts: Clinical Judgment; Professionalism References: Huber (2014), pp. 150–151; Zerwekh, Zerwekh Garneau (2015), p. 510. F u n d a m e n t a l s 75 CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
- 94. UNIT III Nursing Sciences Pyramid to Success Pyramid Points focus on fluids and electrolytes, acid- base balance, laboratory reference intervals, nutrition, intravenous (IV) therapy, and blood administration. Fluids and electrolytes and acid-base balance constitute a content area that is sometimes complex and difficult to understand. For a client who is experiencing these imbal- ances, it is important to remember that maintenance of a patent airway is a priority and the nurse needs to mon- itor vital signs, physiological status, intake and output, laboratory reference intervals, and arterial blood gas values. It is also important to remember that normal lab- oratory reference levels may vary slightly, depending on the laboratory setting and equipment used in testing. If you are familiar with the normal reference intervals, you will be able to determine whether an abnormality exists when a laboratory value is presented in a question. The specific laboratory reference levels identified in the NCLEX® test plan that you need to know include arterial blood gases known as ABGs (pH, PO2, PCO2, SaO2, HCO3), blood urea nitrogen (BUN), cholesterol (total), glucose, hematocrit, hemoglobin, glycosylated hemo- globin (HgbA1C), platelets, potassium, sodium, white blood cell (WBC) count, creatinine, prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR). The questions on the NCLEX-RN examination related to laboratory reference intervals will require you to identify whether the laboratory value is normal or abnormal, and then you will be required to think critically about the effects of the laboratory value in terms of the client. Note the disorder presented in the question and the associated body organ affected as a result of the disorder. This pro- cess will assist you in determining the correct answer. Nutrition is a basic need that must be met for all cli- ents. The NCLEX-RN examination addresses the dietary measures required for basic needs and for particular body system alterations and addresses parenteral nutri- tion (PN), both partial parenteral nutrition (PPN) and total parenteral nutrition (TPN). When presented with a question related to nutrition, consider the client’s diag- nosis and the particular requirement or restriction neces- sary for treatment of the disorder. With regard to IV therapy, assessment of the client for allergies, including latex sensitivity, before initiation of an IVline and mon- itoring for complications are critical nursing responsibil- ities. Likewise, the procedure for administering blood components, the signs and symptoms of transfusion reaction, and the immediate interventions if a transfu- sion reaction occurs are a focus. Client Needs: Learning Objectives Safe and Effective Care Environment Applying principles of infection control Collaborating with interprofessional teams Ensuring that informed consent has been obtained for invasive procedures and for the administration of blood products Establishing priorities for care Handling hazardous and infectious materials to prevent injury to health care personnel and others Identifying the client with at least 2 forms of identifiers (e.g., name and identification number) prior to the administration of a blood product Initiating home health care referrals Maintaining continuity of care and providing close supervision during a blood transfusion Maintaining asepsis and preventing infection in the cli- ent when samples for laboratory studies are obtained or when IV solutions are administered Maintaining standard, transmission-based, and other precautions to prevent transmission of infection to self and others Preventing accidents and ensuring safety of the client when a fluid or electrolyte imbalance exists, particu- larly when changes in cardiovascular, respiratory, gastrointestinal, neuromuscular, renal, or central ner- vous systems occur, or when the client is at risk for complications such as seizures, respiratory depres- sion, or dysrhythmias F u n d a m e n t a l s 76
- 95. Providing information to the client about community classes for nutrition education Providing safety for the client during implementation of treatments Using equipment such as electronic IV infusion devices safely Upholding client rights Health Promotion and Maintenance Assessing the client’s ability to perform self-care Considering lifestyle choices related to home care of the IV line Evaluating the client’s home environment for self-care modifications Identifying clients at risk for an acid-base imbalance Identifying community resources available for follow-up Identifying lifestyle choices related to receiving a blood transfusion Implementing health screening and monitoring for the potential risk for a fluid and electrolyte imbalance Performing physical assessment techniques Providing client and family education regarding the administration of PN at home Providing education related to medication and diet management Providing education related to the potential risk for a fluid and electrolyte imbalance, measures to prevent an imbalance, signs and symptoms of an imbalance, and actions to take if signs and symptoms develop Teaching the client and family about prevention, early detection, and treatment measures for health disorders Teaching the client to monitor for signs and symptoms that indicate the need to notify the health care provider Teaching the client and family about care of the IV line Psychosocial Integrity Assessing the client’s emotional response to treatment Considering cultural and spiritual preferences related to nutritional patterns and lifestyle choices Discussing role changes and alterations in lifestyle related to the client’s need to receive PN Ensuring therapeutic interactions with the client regard- ing the procedure for blood administration Identifying coping mechanisms Identifying religious, spiritual, and cultural consider- ations related to blood administration Identifying support systems in the home to assist with caring for an IV and the administration of PN Providing emotional support to the client during testing Providing reassurance to the client who is experiencing a fluid or electrolyte imbalance Providing support and continuously informing the cli- ent of the purposes for prescribed interventions Physiological Integrity Administering and monitoring medications, IV fluids, and other therapeutic interventions Administering blood products safely Assessing and caring for central venous access devices Assessing for expected and unexpected responses to ther- apeutic interventions and documenting findings Assessing venous access devices for blood administration Assisting with obtaining an ABG specimen and analyz- ing the results Identifying clients who are at risk for a fluid or electrolyte imbalance Maintaining IV therapy Managing medical emergencies if a transfusion reaction or other complication occurs Monitoring for complications related to blood administration Monitoring for complications related to a body system alteration Monitoring for changes in status and for complications; taking actions if a complication arises Monitoring for clinical manifestations associated with an abnormal laboratory value Monitoring of enteral feedings and the client’s ability to tolerate feedings Monitoring for expected effects of pharmacological and parenteral therapies Monitoring laboratory reference intervals; determining the significance of an abnormal laboratory value and the need to implement specific actions based on the laboratory results Monitoring of nutritional intake and oral hydration Providing wound care when blood is obtained for an ABG study Reducing the likelihood that an acid-base imbalance will occur 77 UNIT III Nursing Sciences F u n d a m e n t a l s
- 96. F u n d a m e n t a l s CH AP TER 8 Fluids and Electrolytes PRIORITYCONCEPTS Cellular Regulation; Fluid and Electrolytes CRITICALTHINK ING W hat Should Y ou Do? The nurse notes the presence ofU waves on a client’s cardiac monitor screen. What actions should the nurse take? Answer located on p. 91. I. Concepts of Fluid and Electrolyte Balance A. Electrolytes 1. Description: An electrolyte is a substance that, on dissolving in solution, ionizes; that is, some of its molecules split or dissociate into electrically charged atoms or ions (Box 8-1). 2. Measurement a. The metric system is used to measure volumes of fluids—liters (L) or milliliters (mL). b. The unit of measure that expresses the com- bining activity of an electrolyte is the milliequivalent (mEq). c. One milliequivalent (1 mEq) of any cation always reacts chemically with 1 mEq of an anion. d. Milliequivalents provide information about the number of anions or cations available to combine with other anions or cations. B. Body fluid compartments (Fig. 8-1) 1. Description a. Fluid in each of the body compartments con- tains electrolytes. b. Each compartment has a particular composi- tion of electrolytes, which differs from that of other compartments. c. To function normally, body cells must have fluids and electrolytes in the right compart- ments and in the right amounts. d. Whenever an electrolyte moves out of a cell, another electrolyte moves in to take its place. e. The numbers of cations and anions must be the same for homeostasis to exist. f. Compartments are separated by semiperme- able membranes. 2. Intravascular compartment: Refers to fluid inside a blood vessel 3. Intracellular compartment a. The intracellular compartment refers to all fluid inside the cells. b. Most bodily fluids are inside the cells. 4. Extracellular compartment a. Refers to fluid outside the cells. b. The extracellular compartment includes the interstitial fluid, which is fluid between cells (sometimes called the third space), blood, lymph, bone, connective tissue, water, and transcellular fluid. C. Third-spacing 1. Third-spacing is the accumulation and sequestra- tion of trapped extracellular fluid in an actual or potential body space as a result of disease or injury. 2. The trapped fluid represents a volume loss and is unavailable for normal physiological processes. 3. Fluid may be trapped in body spaces such as the pericardial, pleural, peritoneal, or joint cavities; the bowel; or the abdomen, or within soft tissues after trauma or burns. 4. Assessing the intravascular fluid loss caused by third-spacing is difficult. The loss may not be reflected in weight changes or intake and output records, and may not become apparent until after organ malfunction occurs. D. Edema 1. Edema is an excess accumulation of fluid in the interstitial space; it occurs as a result of alterations in oncotic pressure, hydrostatic pres- sure, capillary permeability, and lymphatic obstruction. 2. Localized edema occurs as a result of traumatic injury from accidents or surgery, local inflamma- tory processes, or burns. 3. Generalized edema, also called anasarca, is an excessive accumulation of fluid in the interstitial 78
- 97. space throughout the body and occurs as a result of conditions such as cardiac, renal, or liver failure. E. Body fluid 1. Description a. Body fluids transport nutrients to the cells and carry waste products from the cells. b. Total body fluid (intracellular and extracellu- lar) amounts to about 60% of body weight in the adult, 55% in the older adult, and 80% in the infant. c. Thus infants and older adults are at a higher risk for fluid-related problems than younger adults; children have a greater proportion of body water than adults and the older adult has the least proportion of body water. 2. Constituents of body fluids a. Body fluids consist of water and dissolved substances. b. The largest single fluid constituent of the body is water. c. Some substances, such as glucose, urea, and creatinine, do not dissociate in solution; that is, they do not separate from their complex forms into simpler substances when they are in solution. d. Other substances do dissociate; for example, when sodium chloride is in a solution, it dis- sociates, or separates, into 2 parts or elements. Infants and older adults need to be monitored closely for fluid imbalances. F. Body fluid transport 1. Diffusion a. Diffusion is the process whereby a solute (substance that is dissolved) may spread through a solution or solvent (solution in which the solute is dissolved). b. Diffusion of a solute spreads the molecules from an area of higher concentration to an area of lower concentration. c. A permeable membrane allows substances to pass through it without restriction. d. A selectively permeable membrane allows some solutes to pass through without restric- tion but prevents other solutes from passing freely. e. Diffusion occurs within fluid compartments and from one compartment to another if the barrier between the compartments is per- meable to the diffusing substances. F u n d a m e n t a l s BOX 8-1 Properties of Electrolytes and Their Components Atom An atom is the smallest part of an element that still has the properties of the element. The atom is composed of particles known as the proton (posi- tive charge), neutron (neutral), and electron (negative charge). Protons and neutrons are in the nucleus of the atom; therefore, the nucleus is positively charged. Electrons carry a negative charge and revolve around the nucleus. As long as the number ofelectrons is the same as the number of protons, the atom has no net charge; that is, it is neither pos- itive nor negative. Atoms that gain, lose, or share electrons are no longer neutral. Molecule A molecule is 2 or more atoms that combine to form a substance. Ion An ion is an atom that carries an electrical charge because it has gained or lost electrons. Some ions carry a negative electrical charge and some carry a positive charge. Cation A cation is an ion that has given away or lost electrons and therefore carries a positive charge. The result is fewer electrons than protons, and the result is a positive charge. Anion An anion is an ion that has gained electrons and therefore carries a negative charge. When an ion has gained or taken on electrons, it assumes a neg- ative charge and the result is a negatively charged ion. Intracellular fluid Extracellular fluid Interstitial Intravascular Transcellular (cerebrospinal canals, lymphatic tissues, synovial joints, and the eye) (70%) (30%) (22%) (6%) (2%) FIGURE 8-1 Distribution of fluid by compartments in the average adult. 79 CHAPTER 8 Fluids and Electrolytes
- 98. F u n d a m e n t a l s 2. Osmosis a. Osmotic pressure is the force that draws the solvent from a less concentrated solute through a selectively permeable membrane into a more concentrated solute, thus tending to equalize the concentration of the solvent. b. If a membrane is permeable to water but not to all solutes present, the membrane is a selec- tive or semipermeable membrane. c. Osmosis is the movement of solvent mole- cules across a membrane in response to a con- centration gradient, usually from a solution of lower to one of higher solute concentration. d. When a more concentrated solution is on one side of a selectively permeable membrane and a less concentrated solution is on the other side, a pull called osmotic pressure draws the water through the membrane to the more concentrated side, or the side with more solute. 3. Filtration a. Filtration is the movement of solutes and sol- vents by hydrostatic pressure. b. The movement is from an area of higher pres- sure to an area of lower pressure. 4. Hydrostatic pressure a. Hydrostatic pressure is the force exerted by the weight of a solution. b. When a difference exists in the hydrostatic pressure on two sides of a membrane, water and diffusible solutes move out of the solu- tion that has the higher hydrostatic pressure by the process of filtration. c. At the arterial end of the capillary, the hydro- static pressure is higher than the osmotic pres- sure; therefore, fluids and diffusible solutes move out of the capillary. d. At the venous end, the osmotic pressure, or pull, is higher than the hydrostatic pressure, and fluids and some solutes move into the capillary. e. The excess fluid and solutes remaining in the interstitial spaces are returned to the intravas- cular compartment by the lymph channels. 5. Osmolality a. Osmolality refers to the number of osmoti- cally active particles per kilogram of water; it is the concentration of a solution. b. In the body, osmotic pressure is measured in milliosmoles (mOsm). c. The normal osmolality of plasma is 275- 295 mOsm/kg (275-295 mmol/kg). G. Movement of body fluid 1. Description a. Cell membranes separate the interstitial fluid from the intravascular fluid. b. Cell membranes are selectively permeable; that is, the cell membrane and the capillary wall allow water and some solutes free pas- sage through them. c. Several forces affect the movement of water and solutes through the walls of cells and cap- illaries; for example, the greater the number of particles within the cell, the more pressure exists to force the water through the cell mem- brane out of the cell. d. If the body loses more electrolytes than fluids, as can happen in diarrhea, then the extracel- lular fluid contains fewer electrolytes or less solute than the intracellular fluid. e. Fluids and electrolytes must be kept in bal- ance for health; when they remain out of bal- ance, death can occur. 2. Isotonic solutions a. When the solutions on both sides of a selec- tively permeable membrane have established equilibrium or are equal in concentration, they are isotonic. b. Isotonic solutions are isotonic to human cells, and thus very little osmosis occurs; iso- tonic solutions have the same osmolality as body fluids. c. Refer to Chapter 13, Table 13-1, for a list of isotonic solutions. 3. Hypotonic solutions a. When a solution contains a lower con- centration of salt or solute than another, more concentrated solution, it is considered hypotonic. b. A hypotonic solution has less salt or more water than an isotonic solution; these solu- tions have lower osmolality than body fluids. c. Hypotonic solutions are hypotonic to the cells; therefore, osmosis would continue in an attempt to bring about balance or equality. d. Refer to Chapter 13, Table 13-1, for a list of hypotonic solutions. 4. Hypertonic solutions a. A solution that has a higher concentration of solutes than another, less concentrated solu- tion is hypertonic; these solutions have a higher osmolality than body fluids. b. Refer to Chapter 13, Table 13-1, for a list of hypertonic solutions. 5. Osmotic pressure a. The amount ofosmoticpressure isdetermined by the concentration of solutes in solution. b. When the solutions on each side of a selec- tively permeable membrane are equal in con- centration, they are isotonic. c. A hypotonic solution has less solute than an isotonic solution, whereas a hypertonic solu- tion contains more solute. d. A solvent moves from the less concentrated solute side to the more concentrated solute side to equalize concentration. 80 UNIT III Nursing Sciences
- 99. F u n d a m e n t a l s 6. Active transport a. If an ion is to move through a membrane from an area of lower concentration to an area of higher concentration, an active trans- port system is necessary. b. An active transport system moves molecules or ions against concentration and osmotic pressure. c. Metabolic processes in the cell supply the energy for active transport. d. Substances that are transported actively through the cell membrane include ions of sodium, potassium, calcium, iron, and hydro- gen; some of the sugars; and the amino acids. H. Body fluid intake and output (Fig. 8-2) 1. Body fluid intake a. Water enters the body through 3 sources— orally ingested liquids, water in foods, and water formed by oxidation of foods. b. About 10 mL of water is released by the metabolism of each 100 calories of fat, carbo- hydrates, or proteins. 2. Body fluid output a. Water lost through the skin is called insensible loss (the individual is unaware of losing that water). b. The amount ofwater lost byperspiration varies according to the temperature of the environ- ment and of the body, but the average amount of loss by perspiration alone is 100 mL/day. c. Water lost from the lungs is called insensible loss and is lost through expired air that is sat- urated with water vapor. d. The amount of water lost from the lungs var- ies with the rate and the depth of respiration. e. Large quantities of water are secreted into the gastrointestinal tract, but almost all of this fluid is reabsorbed. f. Alarge volume of electrolyte-containingliquids moves into the gastrointestinal tract and then returns again to the extracellular fluid. g. Severe diarrhea results in the loss of large quantities of fluids and electrolytes. h. The kidneys play a major role in regulating fluid and electrolyte balance and excrete the largest quantity of fluid. i. Normal kidneys can adjust the amount of water and electrolytes leaving the body. j. The quantity of fluid excreted by the kidneys is determined by the amount of water ingested and the amount of waste and solutes excreted. k. As long as all organs are functioning nor- mally, the body is able to maintain balance in its fluid content. The client with diarrhea is at high risk for a fluid and electrolyte imbalance. I. Maintaining fluid and electrolyte balance 1. Description a. Homeostasis is a term that indicates the rela- tive stability of the internal environment. b. Concentration and composition of body fluids must be nearly constant. c. When one of the substances in a client is defi- cient—either fluids or electrolytes—the sub- stance must be replaced normally by the intake of food and water or by therapy such as intravenous (IV) solutions and medications. d. When the client has an excess of fluid or elec- trolytes, therapy is directed toward assisting the body to eliminate the excess. 2. The kidneys play a major role in controlling bal- ance in fluid and electrolytes. 3. The adrenal glands, through the secretion of aldosterone, also aid in controlling extracellular fluid volume by regulating the amount of sodium reabsorbed by the kidneys. 4. Antidiuretic hormone from the pituitary gland regulates the osmotic pressure of extracellular fluid by regulating the amount of water reab- sorbed by the kidneys. II. Fluid Volume Deficit A. Description 1. Dehydration occurs when the fluid intake of the body is not sufficient to meet the fluid needs of the body. 2. The goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of the fluid volume deficit. B. Types of fluid volume deficits 1. Isotonic dehydration a. Water and dissolved electrolytes are lost in equal proportions. b. Known as hypovolemia, isotonic dehydration is the most common type of dehydration. c. Isotonic dehydration results in decreased cir- culating blood volume and inadequate tissue perfusion. Fluid intake Ingested water Ingested food Metabolic oxidation TOTAL 1200-1500 mL 800-1100 mL 300 mL 2300-2900 mL Fluid output Kidneys Insensible loss through skin Insensible loss through lungs Gastrointestinal tract TOTAL 1500 mL 600-800 mL 400-600 mL 100 mL 2600-3000 mL FIGURE 8-2 Sources of fluid intake and fluid output. 81 CHAPTER 8 Fluids and Electrolytes
- 100. F u n d a m e n t a l s 2. Hypertonic dehydration a. Water loss exceeds electrolyte loss. b. The clinical problems that occur result from alterations in the concentrations of specific plasma electrolytes. c. Fluid moves from the intracellular compart- ment into the plasma and interstitial fluid spaces, causing cellular dehydration and shrinkage. 3. Hypotonic dehydration a. Electrolyte loss exceeds water loss. b. The clinical problems that occur result from fluid shifts between compartments, causing a decrease in plasma volume. c. Fluid moves from the plasma and interstitial fluid spaces into the cells, causing a plasma volume deficit and causing the cells to swell. C. Causes of fluid volume deficits 1. Isotonic dehydration a. Inadequate intake of fluids and solutes b. Fluid shifts between compartments c. Excessive losses of isotonic body fluids 2. Hypertonic dehydration—conditions that increase fluid loss, such as excessive perspiration, hyperventilation, ketoacidosis, prolonged fevers, diarrhea, early-stage kidney disease, and diabetes insipidus 3. Hypotonic dehydration a. Chronic illness b. Excessive fluid replacement (hypotonic) c. Kidney disease d. Chronic malnutrition D. Assessment (Table 8-1) E. Interventions TABLE 8-1 Assessment Findings: Fluid Volume Deficit and Fluid Volume Excess Fluid Volume Deficit Fluid Volume Excess Cardiovascular ▪ Thready, increased pulse rate ▪ Bounding, increased pulse rate ▪ Decreased blood pressure and orthostatic (postural) hypotension ▪ Elevated blood pressure ▪ Flat neck and hand veins in dependent positions ▪ Distended neck and hand veins ▪ Diminished peripheral pulses ▪ Elevated central venous pressure ▪ Decreased central venous pressure ▪ Dysrhythmias ▪ Dysrhythmias Respiratory ▪ Increased rate and depth of respirations ▪ Increased respiratory rate (shallow respirations) ▪ Dyspnea ▪ Dyspnea ▪ Moist crackles on auscultation Neuromuscular ▪ Decreased central nervous system activity, from lethargy to coma ▪ Altered level of consciousness ▪ Fever, depending on the amount of fluid loss ▪ Headache ▪ Skeletal muscle weakness ▪ Visual disturbances ▪ Skeletal muscle weakness ▪ Paresthesias Renal ▪ Decreased urine output ▪ Increased urine output if kidneys can compensate; decreased urine output if kidney damage is the cause Integumentary ▪ Dry skin ▪ Pitting edema in dependent areas ▪ Poor turgor, tenting ▪ Pale, cool skin ▪ Dry mouth Gastrointestinal ▪ Decreased motility and diminished bowel sounds ▪ Increased motility in the gastrointestinal tract ▪ Constipation ▪ Diarrhea ▪ Thirst ▪ Increased body weight ▪ Decreased body weight ▪ Liver enlargement ▪ Ascites Laboratory Findings ▪ Increased serum osmolality ▪ Decreased serum osmolality ▪ Increased hematocrit ▪ Decreased hematocrit ▪ Increased blood urea nitrogen (BUN) level ▪ Decreased BUN level ▪ Increased serum sodium level ▪ Decreased serum sodium level ▪ Increased urinary specific gravity ▪ Decreased urine specific gravity 82 UNIT III Nursing Sciences
- 101. F u n d a m e n t a l s 1. Monitor cardiovascular, respiratory, neuromus- cular, renal, integumentary, and gastrointestinal status. 2. Prevent further fluid losses and increase fluid compartment volumes to normal ranges. 3. Provide oral rehydration therapy if possible and IVfluid replacement if the dehydration is severe; monitor intake and output. 4. In general, isotonic dehydration is treated with isotonic fluid solutions, hypertonic dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic fluid solutions. 5. Administer medications, such as antidiarrheal, antimicrobial, antiemetic, and antipyretic medi- cations, as prescribed to correct the cause and treat any symptoms. 6. Monitor electrolyte values and prepare to admin- ister medication to treat an imbalance, if present. III. Fluid Volume Excess A. Description 1. Fluid intake or fluid retention exceeds the fluid needs of the body. 2. Fluid volume excess is also called overhydration or fluid overload. 3. The goal of treatment is to restore fluid balance, correct electrolyte imbalances if present, and eliminate or control the underlying cause of the overload. B. Types 1. Isotonic overhydration a. Known as hypervolemia, isotonic overhydra- tion results from excessive fluid in the extra- cellular fluid compartment. b. Only the extracellular fluid compartment is expanded, and fluid does not shift between the extracellular and intracellular compartments. c. Isotonic overhydration causes circulatory overload and interstitial edema; when severe or when it occurs in a client with poor cardiac function, heart failure and pulmonary edema can result. 2. Hypertonic overhydration a. The occurrence of hypertonic overhydration is rare and is caused by an excessive sodium intake. b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid volume expands, and the intracellular fluid volume contracts. 3. Hypotonic overhydration a. Hypotonic overhydration is known as water intoxication. b. The excessive fluid moves into the intracellu- lar space, and all body fluid compartments expand. c. Electrolyte imbalances occur as a result of dilution. C. Causes 1. Isotonic overhydration a. Inadequately controlled IV therapy b. Kidney disease c. Long-term corticosteroid therapy 2. Hypertonic overhydration a. Excessive sodium ingestion b. Rapid infusion of hypertonic saline c. Excessive sodium bicarbonate therapy 3. Hypotonic overhydration a. Early kidney disease b. Heart failure c. Syndrome of inappropriate antidiuretic hor- mone secretion d. Inadequately controlled IV therapy e. Replacement of isotonic fluid loss with hypo- tonic fluids f. Irrigation of wounds and body cavities with hypotonic fluids D. Assessment (see Table 8-1) E. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, renal, integumentary, and gastrointestinal status. 2. Prevent further fluid overload and restore nor- mal fluid balance. 3. Administer diuretics; osmotic diuretics may be prescribed initially to prevent severe electrolyte imbalances. 4. Restrict fluid and sodium intake as prescribed. 5. Monitor intake and output; monitor weight. 6. Monitor electrolyte values, and prepare to adminis- ter medication to treat an imbalance if present. A client with acute kidney injury or chronic kidney disease is at high risk for fluid volume excess. IV. Hypokalemia A. Description 1. Hypokalemia is a serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) (Box 8-2). 2. Potassium deficit is potentially life-threatening because every body system is affected. BOX 8-2 Potassium Normal Value 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) Common Food Sources Avocado, bananas, cantaloupe, oranges, strawberries, tomatoes Carrots, mushrooms, spinach Fish, pork, beef, veal Potatoes Raisins 83 CHAPTER 8 Fluids and Electrolytes
- 102. F u n d a m e n t a l s B. Causes 1. Actual total body potassium loss a. Excessive use of medications such as diuretics or corticosteroids b. Increased secretion of aldosterone, such as in Cushing’s syndrome c. Vomiting, diarrhea d. Wound drainage, particularly gastrointestinal e. Prolonged nasogastric suction f. Excessive diaphoresis g. Kidney disease impairing reabsorption of potassium 2. Inadequate potassium intake: Fasting; nothing by mouth status 3. Movement of potassium from the extracellular fluid to the intracellular fluid a. Alkalosis b. Hyperinsulinism 4. Dilution of serum potassium a. Water intoxication b. IVtherapy with potassium-deficient solutions C. Assessment (Tables 8-2 and 8-3) D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, gastrointestinal, and renal status, and place the client on a cardiac monitor. 2. Monitor electrolyte values. 3. Administer potassium supplements orally or intravenously, as prescribed. 4. Oral potassium supplements a. Oralpotassium supplementsmaycausenausea and vomiting and they should not be taken on an empty stomach; if the client complains of abdominal pain, distention, nausea, vomiting, diarrhea, or gastrointestinal bleeding, the sup- plement may need to be discontinued. b. Liquid potassium chloride has an unpleasant taste and should be taken with juice or another liquid. 5. Intravenously administered potassium (Box 8-3) 6. Institute safety measures for the client experienc- ing muscle weakness. 7. If the client is taking a potassium-losing diuretic, it may be discontinued; a potassium-retaining diuretic may be prescribed. 8. Instruct the client about foods that are high in potassium content (see Box 8-2). Potassium is never administered by IV push, intra- muscular, or subcutaneous routes. IV potassium is always diluted and administered using an infusion device! V. Hyperkalemia A. Description 1. Hyperkalemia is a serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) (see Box 8-2). 2. Pseudohyperkalemia: a condition that can occur due to methods of blood specimen collection and cell lysis; if an increased serum value is obtained in the absence of clinical symptoms, the speci- men should be redrawn and evaluated. B. Causes 1. Excessive potassium intake a. Overingestion of potassium-containing foods or medications, such as potassium chloride or salt substitutes b. Rapid infusion of potassium-containing IV solutions 2. Decreased potassium excretion TABLE 8-2 Assessment Findings: Hypokalemia and Hyperkalemia Hypokalemia Hyperkalemia Cardiovascular ▪ Thready, weak, irregular pulse ▪ Slow, weak, irregular heart rate ▪ Weak peripheral pulses ▪ Decreased blood pressure ▪ Orthostatic hypotension Respiratory ▪ Shallow, ineffective respirations that result from profound weakness of the skeletalmuscles ofrespiration ▪ Profound weakness of the skeletal muscles leading to respiratory failure ▪ Diminished breath sounds Neuromuscular ▪ Anxiety, lethargy, confusion, coma ▪ Early: Muscle twitches, cramps, paresthesias (tingling and burning followed by numbness in the hands and feet and around the mouth) ▪ Skeletal muscle weakness, leg cramps ▪ Late: Profound weakness, ascending flaccid paralysis in the arms and legs (trunk, head, and respiratorymuscles become affected when the serum potassium level reaches a lethal level) ▪ Loss of tactile discrimination ▪ Paresthesias ▪ Deep tendon hyporeflexia Gastrointestinal ▪ Decreased motility, hypoactive to absent bowel sounds ▪ Increased motility, hyperactive bowel sounds ▪ Nausea, vomiting, constipation, abdominal distention ▪ Diarrhea ▪ Paralytic ileus Laboratory Findings ▪ Serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) ▪ Serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) ▪ Electrocardiogram changes: ST depression; shallow, flat, or inverted T wave; and prominent U wave ▪ Electrocardiographic changes: Tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR intervals 84 UNIT III Nursing Sciences
- 103. F u n d a m e n t a l s a. Potassium-retaining diuretics b. Kidney disease c. Adrenal insufficiency, such as in Addison’s disease 3. Movement of potassium from the intracellular fluid to the extracellular fluid a. Tissue damage b. Acidosis c. Hyperuricemia d. Hypercatabolism C. Assessment (see Tables 8-2 and 8-3) Monitor the client closely for signs of a potassium imbalance. A potassium imbalance can cause cardiac dysrhythmias that can be life-threatening! D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, renal, and gastrointestinal status; place the client on a cardiac monitor. 2. DiscontinueIVpotassium (keep theIVcatheterpat- ent), and withhold oral potassium supplements. 3. Initiate a potassium-restricted diet. 4. Prepare to administer potassium-excreting diuretics if renal function is not impaired. 5. If renal function is impaired, prepare to administer sodium polystyrene sulfonate (oral or rectal route), a cation-exchangeresin that promotesgastrointesti- nal sodium absorption and potassium excretion. 6. Prepare the client for dialysis if potassium levels are critically high. 7. Prepare for the administration of IV calcium if hyperkalemia is severe, to avert myocardial excitability. 8. Prepare for the IV administration of hypertonic glucose with regular insulin to move excess potassium into the cells. 9. When blood transfusions are prescribed for a cli- ent with a potassium imbalance, the client should receive fresh blood, if possible; transfu- sions of stored blood may elevate the potassium level because the breakdown of older blood cells releases potassium. 10. Teach the client to avoid foods high in potassium (see Box 8-2). 11. Instruct the client to avoid the use of salt substi- tutes or other potassium-containing substances. Monitor the serum potassium level closely when a client is receiving a potassium-retaining diuretic! VI. Hyponatremia A. Description 1. Hyponatremia is a serum sodium level lower than 135 mEq/L (135 mmol/L) (Box 8-4). TABLE 8-3 Electrocardiographic Changes in Electrolyte Imbalances Electrolyte Imbalance Electrocardiographic Changes Hypocalcemia Prolonged ST segment Prolonged QT interval Hypercalcemia Shortened ST segment Widened T wave Hypokalemia ST depression Shallow, flat, or inverted T wave Prominent U wave Hyperkalemia Tall peaked T waves Flat P waves Widened QRS complexes Prolonged PR interval Hypomagnesemia Tall T waves Depressed ST segment Hypermagnesemia Prolonged PR interval Widened QRS complexes BOX 8-3 Precautions with Intravenously Administered Potassium ▪ Potassium is never given by intravenous (IV) push or by the intramuscular or subcutaneous route. ▪ Adilution of no more than 1mEq/10 mL(1mmol/10 mL) of solution is recommended. ▪ Manyhealth care agencies supplyprepared IVsolutions con- taining potassium; before administering and frequentlydur- ing infusion of the IV solution, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution. ▪ Ensure that the IV bag containing potassium is properly labeled. ▪ The maximum recommended infusion rate is 5 to 10 mEq/ hour (5 to 10 mmol/hour), never to exceed 20 mEq/hour (20 mmol/hour) under any circumstances. ▪ A client receiving more than 10 mEq/hour (10 mmol/hour) should be placed on a cardiac monitor and monitored for cardiac changes, and the infusion should be controlled by an infusion device. ▪ Potassium infusion can cause phlebitis; therefore, the nurse should assess the IVsite frequently for signs of phlebitis or infiltration. If either occurs, the infusion should be stopped immediately. ▪ The nurse should assess renal function before administering potassium, and monitor intake and output during administration. 85 CHAPTER 8 Fluids and Electrolytes
- 104. 2. Sodium imbalances usually are associated with fluid volume imbalances. B. Causes 1. Increased sodium excretion a. Excessive diaphoresis b. Diuretics c. Vomiting d. Diarrhea e. Wound drainage, especially gastrointestinal f. Kidney disease g. Decreased secretion of aldosterone 2. Inadequate sodium intake a. Fasting; nothing by mouth status b. Low-salt diet 3. Dilution of serum sodium a. Excessive ingestion of hypotonic fluids or irri- gation with hypotonic fluids b. Kidney disease c. Freshwater drowning d. Syndrome of inappropriate antidiuretic hor- mone secretion e. Hyperglycemia f. Heart failure C. Assessment (Table 8-4) D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, cerebral, renal, and gastrointestinal status. 2. If hyponatremia is accompanied by a fluid vol- ume deficit (hypovolemia), IV sodium chloride infusions are administered to restore sodium content and fluid volume. 3. If hyponatremia is accompanied by fluid volume excess (hypervolemia), osmotic diuretics may be prescribed to promote the excretion of water rather than sodium. 4. If caused by inappropriate or excessive secretion of antidiuretic hormone, medications that antagonize antidiuretic hormone may be administered. 5. Instruct the client to increase oral sodium intake as prescribed and inform the client about the foods to include in the diet (see Box 8-4). 6. If the client is taking lithium, monitor the lithium level, because hyponatremia can cause dimin- ished lithium excretion, resulting in toxicity. Hyponatremia precipitates lithium toxicity in a client taking lithium. VII. Hypernatremia A. Description: Hypernatremia is a serum sodium level that exceeds 145 mEq/L(145 mmol/L) (see Box 8-4). B. Causes 1. Decreased sodium excretion a. Corticosteroids b. Cushing’s syndrome c. Kidney disease d. Hyperaldosteronism 2. Increased sodium intake: Excessive oral sodium ingestion or excessive administration of sodium-containing IV fluids 3. Decreased water intake: Fasting; nothing by mouth status 4. Increased water loss: Increased rate of metabo- lism, fever, hyperventilation, infection, excessive diaphoresis, watery diarrhea, diabetes insipidus C. Assessment (see Table 8-4) D. Interventions 1. Monitor cardiovascular, respiratory, neuro- muscular, cerebral, renal, and integumentary status. 2. If the cause is fluid loss, prepare to administer IV infusions. 3. If the cause is inadequate renal excretion of sodium, prepare to administer diuretics that pro- mote sodium loss. 4. Restrict sodium and fluid intake as prescribed (see Box 8-4). VIII. Hypocalcemia A. Description: Hypocalcemia is a serum calcium level lower than 9.0 mg/dL (2.25 mmol/L) (Box 8-5). B. Causes 1. Inhibition of calcium absorption from the gas- trointestinal tract a. Inadequate oral intake of calcium b. Lactose intolerance c. Malabsorption syndromes such as celiac sprue or Crohn’s disease d. Inadequate intake of vitamin D e. End-stage kidney disease 2. Increased calcium excretion a. Kidney disease, polyuric phase b. Diarrhea c. Steatorrhea d. Wound drainage, especially gastrointestinal F u n d a m e n t a l s BOX 8-4 Sodium Normal Value 135 to 145 mEq/L (135 to 145 mmol/L) Common Food Sources Bacon, frankfurters, lunch meat Butter, cheese Canned food Ketchup, mustard Milk Processed food Snack foods Soy sauce Table salt 86 UNIT III Nursing Sciences
- 105. 3. Conditions that decrease the ionized fraction of calcium a. Hyperproteinemia b. Alkalosis c. Medications such as calcium chelators or binders d. Acute pancreatitis e. Hyperphosphatemia f. Immobility g. Removal or destruction of the parathyroid glands C. Assessment (Table 8-5 and Fig. 8-3; also see Table 8-3) D. Interventions F u n d a m e n t a l s TABLE 8-4 Assessment Findings: Hyponatremia and Hypernatremia Hyponatremia Hypernatremia Cardiovascular ▪ Symptoms vary with changes in vascular volume ▪ Heart rate and blood pressure respond to vascular volume status ▪ Normovolemic: Rapid pulse rate, normal blood pressure ▪ Hypovolemic: Thready, weak, rapid pulse rate; hypotension; flat neck veins; normal or low central venous pressure ▪ Hypervolemic: Rapid, bounding pulse; blood pressure normal or elevated; normal or elevated central venous pressure Respiratory ▪ Shallow, ineffective respiratory movement is a late manifestation related to skeletal muscle weakness ▪ Pulmonary edema if hypervolemia is present Neuromuscular ▪ Generalized skeletal muscle weakness that is worse in the extremities ▪ Early: Spontaneous muscle twitches; irregular muscle contractions ▪ Diminished deep tendon reflexes ▪ Late: Skeletal muscle weakness; deep tendon reflexes diminished or absent Central Nervous System ▪ Headache ▪ Altered cerebral function is the most common manifestation of hypernatremia ▪ Personality changes ▪ Normovolemia or hypovolemia: Agitation, confusion, seizures ▪ Confusion ▪ Hypervolemia: Lethargy, stupor, coma ▪ Seizures ▪ Coma Gastrointestinal ▪ Increased motility and hyperactive bowel sounds ▪ Extreme thirst ▪ Nausea ▪ Abdominal cramping and diarrhea Renal ▪ Increased urinary output ▪ Decreased urinary output Integumentary ▪ Dry mucous membranes ▪ Dry and flushed skin ▪ Dry and sticky tongue and mucous membranes ▪ Presence or absence of edema, depending on fluid volume changes Laboratory Findings ▪ Serum sodium level less than 135 mEq/L (135 mmol/L) ▪ Serum sodium levelthat exceeds 145mEq/L(145mmol/L) ▪ Decreased urinary specific gravity ▪ Increased urinary specific gravity BOX 8-5 Calcium Normal Value 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L) Common Food Sources Cheese Collard greens Kale Milk and soy milk Rhubarb Sardines Tofu Yogurt 87 CHAPTER 8 Fluids and Electrolytes
- 106. F u n d a m e n t a l s 1. Monitor cardiovascular, respiratory, neuromus- cular, and gastrointestinal status; place the client on a cardiac monitor. 2. Administer calcium supplements orally or cal- cium intravenously. 3. When administeringcalcium intravenously, warm the injection solution to body temperature before administration and administerslowly;monitorfor electrocardiographic changes, observe for infiltra- tion, and monitor for hypercalcemia. 4. Administer medications that increase calcium absorption. a. Aluminum hydroxide reduces phosphorus levels, causing the countereffect of increasing calcium levels. b. Vitamin D aids in the absorption of calcium from the intestinal tract. 5. Provide a quiet environment to reduce environ- mental stimuli. 6. Initiate seizure precautions. 7. Move the client carefully, and monitor for signs of a pathological fracture. 8. Keep 10% calcium gluconate available for treat- ment of acute calcium deficit. TABLE 8-5 Assessment Findings: Hypocalcemia and Hypercalcemia Hypocalcemia Hypercalcemia Cardiovascular ▪ Decreased heart rate ▪ Increased heart rate in the early phase; bradycardia that can lead to cardiac arrest in late phases ▪ Hypotension ▪ Increased blood pressure ▪ Diminished peripheral pulses ▪ Bounding, full peripheral pulses Respiratory ▪ Not directlyaffected; however, respiratoryfailure or arrest can result from decreased respiratory movement because of muscle tetany or seizures ▪ Ineffective respiratorymovement as a result of profound skeletal muscle weakness Neuromuscular ▪ Irritable skeletal muscles: Twitches, cramps, tetany, seizures ▪ Profound muscle weakness ▪ Painful muscle spasms in the calf or foot during periods of inactivity ▪ Diminished or absent deep tendon reflexes ▪ Paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs ▪ Disorientation, lethargy, coma ▪ Positive Trousseau’s and Chvostek’s signs ▪ Hyperactive deep tendon reflexes ▪ Anxiety, irritability Renal ▪ Urinary output varies depending on the cause ▪ Urinary output varies depending on the cause Gastrointestinal ▪ Increased gastric motility; hyperactive bowel sounds ▪ Decreased motility and hypoactive bowel sounds ▪ Cramping, diarrhea ▪ Anorexia, nausea, abdominal distention, constipation Laboratory Findings ▪ Serum calcium level less than 9.0 mg/dL (2.25 mmol/L) ▪ Serum calcium level that exceeds 10.5 mg/dL (2.75 mmol/L) ▪ Electrocardiographic changes: Prolonged ST interval, prolonged QT interval ▪ Electrocardiographic changes: Shortened ST segment, widened T wave A B C FIGURE8-3 Tests for hypocalcemia. A, Chvostek’s sign is contraction offacialmuscles in response to a light tap over the facialnerve in front ofthe ear. B, Trousseau’s sign is a carpal spasm induced by inflating a blood pressure cuff (C) above the systolic pressure for a few minutes. 88 UNIT III Nursing Sciences
- 107. F u n d a m e n t a l s 9. Instruct the client to consume foods high in cal- cium (see Box 8-5). IX. Hypercalcemia A. Description: Hypercalcemia is a serum calcium level that exceeds 10.5 mg/dL(2.75 mmol/L) (see Box8-5). B. Causes 1. Increased calcium absorption a. Excessive oral intake of calcium b. Excessive oral intake of vitamin D 2. Decreased calcium excretion a. Kidney disease b. Use of thiazide diuretics 3. Increased bone resorption of calcium a. Hyperparathyroidism b. Hyperthyroidism c. Malignancy (bone destruction from meta- static tumors) d. Immobility e. Use of glucocorticoids 4. Hemoconcentration a. Dehydration b. Use of lithium c. Adrenal insufficiency C. Assessment (see Tables 8-3 and 8-5) D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, renal, and gastrointestinal status; place the client on a cardiac monitor. 2. Discontinue IVinfusions of solutions containing calcium and oral medications containing cal- cium or vitamin D. 3. Thiazide diuretics may be discontinued and replaced with diuretics that enhance the excre- tion of calcium. 4. Administer medications as prescribed that inhibit calcium resorption from the bone, such as phosphorus, calcitonin, bisphosphonates, and prostaglandin synthesis inhibitors (acetylsa- licylic acid, nonsteroidal antiinflammatory medications). 5. Prepare the client with severe hypercalcemia for dialysis if medications fail to reduce the serum calcium level. 6. Move the client carefully and monitor for signs of a pathological fracture. 7. Monitor for flank or abdominalpain,and strain the urine to check for the presence of urinary stones. 8. Instruct the client to avoid foods high in calcium (see Box 8-5). A client with a calcium imbalance is at risk for a pathological fracture. Move the client carefully and slowly; assist the client with ambulation. X. Hypomagnesemia A. Description: Hypomagnesemia is a serum magnesium level lower than 1.3 mEq/L(0.65 mmol/L) (Box 8-6). B. Causes 1. Insufficient magnesium intake a. Malnutrition and starvation b. Vomiting or diarrhea c. Malabsorption syndrome d. Celiac disease e. Crohn’s disease 2. Increased magnesium excretion a. Medications such as diuretics b. Chronic alcoholism 3. Intracellular movement of magnesium a. Hyperglycemia b. Insulin administration c. Sepsis C. Assessment (Table 8-6; also see Table 8-3) D. Interventions 1. Monitor cardiovascular, respiratory, gastrointes- tinal, neuromuscular, and central nervous sys- tem status; place the client on a cardiac monitor. 2. Because hypocalcemia frequently accompanies hypomagnesemia, interventions also aim to restore normal serum calcium levels. 3. Oral preparations of magnesium may cause diar- rhea and increase magnesium loss. 4. Magnesium sulfate by the IV route may be pre- scribed in ill clients when the magnesium level is low (intramuscular injections cause pain and tis- sue damage); initiate seizure precautions, monitor serum magnesium levels frequently, and monitor for diminished deep tendon reflexes, suggesting hypermagnesemia, during the administration of magnesium. 5. Instruct the client to increase the intake of foods that contain magnesium (see Box 8-6). XI. Hypermagnesemia A. Description: Hypermagnesemia is a serum magne- sium level that exceeds 2.1 mEq/L (1.05 mmol/L) (see Box 8-6). BOX 8-6 Magnesium Normal Value 1.3 to 2.1mEq/L (0.65 to 1.05 mmol/L) Common Food Sources Avocado Canned white tuna Cauliflower Green leafy vegetables, such as spinach and broccoli Milk Oatmeal, wheat bran Peanut butter, almonds Peas Pork, beef, chicken, soybeans Potatoes Raisins Yogurt 89 CHAPTER 8 Fluids and Electrolytes
- 108. B. Causes 1. Increased magnesium intake a. Magnesium-containing antacids and laxatives b. Excessive administration of magnesium intravenously 2. Decreased renal excretion of magnesium as a result of renal insufficiency C. Assessment (see Tables 8-3 and 8-6) D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, and central nervous system status; place the client on a cardiac monitor. 2. Diuretics are prescribed to increase renal excre- tion of magnesium. 3. Intravenously administered calcium chloride or calcium gluconate may be prescribed to reverse the effects of magnesium on cardiac muscle. 4. Instruct the client to restrict dietary intake of magnesium-containing foods (see Box 8-6). 5. Instruct the client to avoid the use of laxatives and antacids containing magnesium. Calcium gluconate is the antidote for magnesium overdose. XII. Hypophosphatemia A. Description 1. Hypophosphatemia is a serum phosphorus (phosphate) level lower than 3.0 mg/dL (0.97 mmol/L) (Box 8-7). 2. A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level. B. Causes 1. Insufficient phosphorus intake: Malnutrition and starvation 2. Increased phosphorus excretion a. Hyperparathyroidism b. Malignancy c. Use of magnesium-based or aluminum hydroxide–based antacids 3. Intracellular shift a. Hyperglycemia b. Respiratory alkalosis C. Assessment 1. Cardiovascular a. Decreased contractility and cardiac output b. Slowed peripheral pulses 2. Respiratory: Shallow respirations 3. Neuromuscular a. Weakness b. Decreased deep tendon reflexes c. Decreased bone density that can cause frac- tures and alterations in bone shape d. Rhabdomyolysis 4. Central nervous system a. Irritability b. Confusion c. Seizures 5. Hematological a. Decreased platelet aggregation and increased bleeding b. Immunosuppression D. Interventions 1. Monitor cardiovascular, respiratory, neuromus- cular, central nervous system, and hematological status. F u n d a m e n t a l s TABLE 8-6 Assessment Findings: Hypomagnesemia and Hypermagnesemia Hypomagnesemia Hypermagnesemia Cardiovascular ▪ Tachycardia ▪ Bradycardia, dysrhythmias ▪ Hypertension ▪ Hypotension Respiratory ▪ Shallow respirations ▪ Respiratory insufficiency when the skeletal muscles of respiration are involved Neuromuscular ▪ Twitches, paresthesias ▪ Diminished or absent deep tendon reflexes ▪ Positive Trousseau’s and Chvostek’s signs ▪ Skeletal muscle weakness ▪ Hyperreflexia ▪ Tetany, seizures Central Nervous System ▪ Irritability ▪ Drowsiness and lethargy that progresses to coma ▪ Confusion Laboratory Findings ▪ Serum magnesium level less than 1.3 mEq/L (0.65 mmol/L) ▪ Serum magnesium level that exceeds 2.1mEq/L (1.05 mmol/L) ▪ Electrocardiographic changes: Tall T waves, depressed ST segments ▪ Electrocardiographic changes: Prolonged PR interval, widened QRS complexes BOX 8-7 Phosphorus (Phosphate) Normal Value 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L) Common Food Sources Dairy products Fish Nuts Pork, beef, chicken, organ meats Pumpkin, squash Whole-grain breads and cereals 90 UNIT III Nursing Sciences
- 109. F u n d a m e n t a l s 2. Discontinue medications that contribute to hypophosphatemia. 3. Administer phosphorus orally along with a vita- min D supplement. 4. Prepare to administer phosphorus intravenously when serum phosphorus levels fall below 1 mg/ dL and when the client experiences critical clini- cal manifestations. 5. Administer IVphosphorus slowly because of the risks associated with hyperphosphatemia. 6. Assess the renal system before administering phosphorus. 7. Move the client carefully, and monitor for signs of a pathological fracture. 8. Instruct the client to increase the intake of the phosphorus-containing foods while decreasing the intake of any calcium-containing foods (see Boxes 8-5 and 8-7). Adecrease in the serum phosphorus level is accom- panied byan increase in the serum calcium level, and an increase in the serum phosphorus level is accompanied bya decrease in the serum calcium level. This is called a reciprocal relationship. XIII. Hyperphosphatemia A. Description 1. Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L) (see Box 8-7). 2. Most body systems tolerate elevated serum phos- phorus levels well. 3. An increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level. 4. The problems that occur in hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase. B. Causes 1. Decreased renal excretion resulting from renal insufficiency 2. Tumor lysis syndrome 3. Increased intake of phosphorus, including die- tary intake or overuse of phosphate-containing laxatives or enemas 4. Hypoparathyroidism C. Assessment: Refer to assessment of hypocalcemia. D. Interventions 1. Interventions entail the management of hypocalcemia. 2. Administer phosphate-binding medications that increase fecal excretion of phosphorus by binding phosphorusfrom food in the gastrointestinaltract. 3. Instruct the client to avoid phosphate-containing- medications, including laxatives and enemas. 4. Instruct the client to decrease the intake of food that is high in phosphorus (see Box 8-7). 5. Instruct the client in medication administration: Take phosphate-binding medications, emphasiz- ing that they should be taken with meals or immediately after meals. CRITICALTHINK ING W hat Should Y ou Do? Answer: Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client’s vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client’s most recent serum potassium level and then contact the health care provider to report the findings and obtain prescriptions to treat the hypokalemic state. Reference: Lewis et al. (2014), pp. 297–298. P RAC TI C E Q U ES TI O N S 36. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dys- pneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP) 37. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison’s disease 4. Uric acid level of 9.4 mg/dL (559 µmol/L) 38. The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex 91 CHAPTER 8 Fluids and Electrolytes
- 110. F u n d a m e n t a l s 39. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administra- tion of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. 40. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries 41. The nurse is reviewing laboratory results and notes that a client’s serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1. Peas 2. Nuts 3. Cheese 4. Cauliflower 5. Processed oat cereals 42. The nurse is assessing a client with a suspected diag- nosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau’s sign 4. Hypoactive deep tendon reflexes 43. The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment 44. The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes 45. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing’s syndrome 4. The client who is taking corticosteroids 46. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine 47. The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phos- phate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phospho- rus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome 48. The nurse is reading a health care provider’s (HCP’s) progress notes in the client’s record and reads that the HCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract 49. The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 92 UNIT III Nursing Sciences
- 111. 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations 50. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assess- ment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure 51. On review of the clients’ medical records, the nurse determines that which client is at risk for fluid vol- ume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointes- tinal suctioning 4. The client with kidney disease and a 12-year his- tory of diabetes mellitus 52. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing’s syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn AN S WERS 36. 3 Rationale: Afluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings asso- ciated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease. Review: The assessment findings noted in fluid volume excess Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Fluid and Electrolytes; Perfusion References: Ignatavicius, Workman (2016), pp. 158–159; Lewis et al. (2014), pp. 292–293. 37. 2 Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s dis- ease and the client with hyperuricemia are at risk for hyperkale- mia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL(0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. Test-Taking Strategy: Note that the subject of the question is potassium deficit. First recall the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid. Review: The causes of hypokalemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), pp. 296, 1211. 38. 1, 3, 4 Rationale: The normal serum potassium level is3.5 to 5.0 mEq/L (3.5to 5.0 mmol/L).Aserum potassium levellowerthan 3.5 mEq/ L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can bepotentiallylife-threatening. Elec- trocardiographicchangesincludeshallow,flat,orinverted Twaves; STsegmentdepression;andprominentUwaves.AbsentPwavesare notacharacteristicofhypokalemiabutmaybenotedin aclientwith atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia. Test-Taking Strategy: Focus on the subject, the ECG patterns that may be noted with a client with a potassium level of 2.5 mEq/L (2.5 mmol/L). From the information in the ques- tion, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the elec- trocardiographic changes that are expected when severe hypo- kalemia exists. Review: The electrocardiographic changes that occur in hypokalemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes References: Ignatavicius, Workman (2016), pp. 163–164; Lewis et al. (2014), p. 298. F u n d a m e n t a l s 93 CHAPTER 8 Fluids and Electrolytes
- 112. 39. 1, 2, 4, 5, 6 Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IVbag con- taining the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the uri- nary output is less than 30 mL/hour. Test-Taking Strategy: Focus on the subject, the preparation and administration of potassium chloride intravenously. Think about this procedure and the effects of potassium. Note the word bolus in option 3 to assist in eliminating this option. Review: The precautions with intravenously administered potassium Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Pharmacology—Cardiovascular Medications Priority Concepts: Clinical Judgment; Safety References: Gahart, Nazareno (2015), pp. 1009–1011; Lewis et al. (2014), p. 298. 40. 2, 3, 4, 6 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mush- rooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium. Test-Taking Strategy: Focus on the subject, foods high in potassium. Read each food item and use knowledge about nutrition and components of food. Recall that peas and cauli- flower are high in magnesium. Review: The food items high in potassium content Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Client Education; Nutrition References: Lewis et al. (2014), pp. 296, 1115; Nix (2013), p. 138. 41. 1, 2, 4 Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content. Test-Taking Strategy: Focus on the subject, foods acceptable to be consumed by a client with a sodium level of 150 mEq/L (150 mmol/L). First, you must determine that the client has hypernatremia. Select peas and cauliflower first because these are vegetables. From the remaining options, note the word pro- cessed in option 5 and recall that cheese is high in sodium. Remember that processed foods tend to be higher in sodium content. Review: Foods high in sodium content Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Client Education; Nutrition References: Lewis et al. (2014), p. 295; Nix (2013), p. 141. 42. 1 Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitch- ing, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Test-Taking Strategy: Note that the three incorrect options are comparable or alike in that they reflect a hypoactivity. The option that is different is the correct option. Review: The manifestations of hypocalcemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), pp. 299–300. 43. 4, 5 Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocar- diographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia. Test-Taking Strategy: Focus on the subject, the electrocardio- graphic patterns that occur in a calcium imbalance. It is neces- sary to know the electrocardiographic changes that occur in hypocalcemia. Remember that hypocalcemia causes a pro- longed ST segment and prolonged QT interval. Review: The electrocardiographic changes that occur in hypocalcemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 299. 44. 3, 5 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than F u n d a m e n t a l s 94 UNIT III Nursing Sciences
- 113. 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocar- diographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia. Test-Taking Strategy: Focus on the subject, the electrocardio- graphic changes that occur in a potassium imbalance. From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. Remember that tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR interval are associated with hyperkalemia. Review: The electrocardiographic changes that occur in hyperkalemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 296. 45. 1 Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticoste- roids and the client with hyperaldosteronism or Cushing’s syn- drome are at risk for hypernatremia. Test-Taking Strategy: Focus on the subject, the causes of a sodium level of 130 mEq/L (130 mmol/L). First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to the correct option. Also, recall that when a client takes a diuretic, the client loses fluid and electrolytes. Review: The normal serum sodium level and the causes of hyponatremia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), pp. 295–296. 46. 3 Rationale: The normal serum sodium level is135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperac- tive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted. Test-Taking Strategy: Focus on the data in the question and the subject of the question, signs of hyponatremia. It is necessary to know the signs of hyponatremia to answer correctly. Also, think about the action and effects of sodium on the body to answer correctly. Remember that increased bowel motility and hyperactive bowel sounds indicate hyponatremia. Review: The signs associated with hyponatremia and hypernatremia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 295. 47. 1 Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydrox- ide–based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, a serum phosphorus level of 1.8 mg/ dL (0.45 mmol/L). First, you must determine that the client is experiencing hypophosphatemia. From this point, think about the effects of phosphorus on the body and recall the causes of hypophosphatemia in order to answer correctly. Review: The causative factors associated with hypopho- sphatemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 301. 48. 3 Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastro- intestinal tract losses. Test-Taking Strategy: Note that the subject of the question is insensible fluid loss. Note that urination, wound drainage, and gastrointestinal tract losses are comparable or alike in that they can be measured for accurate output. Fluid loss through the skin cannot be measured accurately; it can only be approximated. Review: The difference between sensible and insensible fluid loss Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes References: Lewis et al. (2014), pp. 290, 293; Perry, Potter, Ostendorf (2014), p. 810. 49. 1 Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, F u n d a m e n t a l s 95 CHAPTER 8 Fluids and Electrolytes
- 114. and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess. Test-Taking Strategy: Note the strategic words, most likely. Read the question carefully, noting the subject, the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients with heart failure, on long-term corticosteroid therapy, and receiving frequent wound irrigations retain fluid. The only condition that can cause a deficit is the condition noted in the correct option. Review: The causes of a fluid volume deficit Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 292. 50. 1 Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess. Test-Taking Strategy: Focus on the subject, fluid volume def- icit. Think about the pathophysiology for fluid volume deficit and fluid volume excess to answer correctly. Note that options 2, 3, and 4 are comparable or alike and are manifestations associated with fluid volume excess. Review: The assessment findings noted in fluid volume deficit Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 292. 51. 4 Rationale: Afluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irri- gation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileos- tomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit. Test-Taking Strategy: Focus on the subject, fluid volume excess. Think about the pathophysiology associated with fluid volume excess. Read each option and think about the fluid imbalance that can occur in each. Clients taking diuretics or having ileostomies or gastrointestinal suctioning all lose fluid. The only condition that can cause an excess is the condition noted in the correct option. Review: The causes of fluid volume excess Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), pp. 292, 299–300. 52. 4 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkale- mia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. Test-Taking Strategy: Eliminate the client with colitis and the client overusing laxatives first because they are comparable or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potas- sium shifts will assist in directing you to the correct option. Also, remember that Cushing’s syndrome presents a risk for hypokalemia and that Addison’s disease presents a risk for hyperkalemia. Review: The risk factors associated with hyperkalemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Fluids & Electrolytes Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 296. F u n d a m e n t a l s 96 UNIT III Nursing Sciences
- 115. F u n d a m e n t a l s CH AP TER 9 Acid-Base Balance PRIORITYCONCEPTS A cid-Base Balance; Oxygenation CRITICALTHINK ING W hat Should Y ou Do? The nurse performs an Allen’s test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. The nurse should take which actions? Answer located on p. 103. I. Hydrogen Ions, Acids, and Bases A. Hydrogen ions 1. Vital to life and expressed as pH. 2. Circulate in the body in 2 forms: a. Volatile hydrogen of carbonic acid b. Nonvolatileform ofhydrogen and organicacids B. Acids 1. Acids are produced as end products of metabolism. 2. Acids contain hydrogen ions and are hydrogen ion donors, which means that acids give up hydrogen ions to neutralize or decrease the strength of an acid or to form a weaker base. 3. The strength of an acid is determined by the number of hydrogen ions it contains. 4. The number of hydrogen ions in body fluid determines its acidity, alkalinity, or neutrality. 5. The lungs excrete 13,000 to 30,000 mEq/day of volatile hydrogen in the form of carbonic acid as carbon dioxide (CO2). 6. The kidneys excrete 50 mEq/day of nonvolatile acids. C. Bases 1. Contain no hydrogen ions. 2. Are hydrogen ion acceptors; they accept hydro- gen ions from acids to neutralize or decrease the strength of a base or to form a weaker acid. II. RegulatorySystems for Hydrogen Ion Concentration in the Blood A. Buffers 1. Buffers are the fastest acting regulatory system. 2. Buffers provide immediate protection against changes in hydrogen ion concentration in the extracellular fluid. 3. Buffers are reactors that function only to keep the pH within the narrow limits of stability when too much acid or base is released into the system, and buffers absorb or release hydrogen ions as needed. 4. Buffers serve as a transport mechanism that carries excess hydrogen ions to the lungs. 5. Once the primary buffer systems react, they are consumed, leaving the body less able to withstand further stress until the buffers are replaced. B. Primary buffer systems in extracellular fluid 1. Hemoglobin system a. System maintains acid-base balance by a pro- cess called chloride shift. b. Chloride shifts in and out of the cells in response to the level of oxygen (O2) in the blood. c. For each chloride ion that leaves a red blood cell, a bicarbonate ion enters. d. For each chloride ion that enters a red blood cell, a bicarbonate ion leaves. 2. Plasma protein system a. The system functions along with the liver to vary the amount of hydrogen ions in the chemical structure of plasma proteins. b. Plasma proteins have the ability to attract or release hydrogen ions. 3. Carbonic acid–bicarbonate system a. Primary buffer system in the body. b. The system maintains a pH of 7.4 with a ratio of 20 parts bicarbonate (HCO3 À ) to 1 part carbonic acid (H2CO3) (Fig. 9-1). c. This ratio (20:1) determines the hydrogen ion concentration of body fluid. d. Carbonic acid concentration is controlled by the excretion of CO2 by the lungs; the rate and depth of respiration change in response to changes in the CO2. 97
- 116. F u n d a m e n t a l s e. The kidneys control the bicarbonate concen- tration and selectively retain or excrete bicar- bonate in response to bodily needs. 4. Phosphate buffer system a. System is present in the cells and body fluids and is especially active in the kidneys. b. System acts like bicarbonate and neutralizes excess hydrogen ions. C. Lungs 1. The lungs are the second defense of the body and interact with the buffer system to maintain acid- base balance. 2. In acidosis, the pH decreases and the respiratory rate and depth increase in an attempt to exhale acids. The carbonic acid created by the neutraliz- ing action of bicarbonate can be carried to the lungs, where it is reduced to CO2 and water and is exhaled; thus hydrogen ions are inacti- vated and exhaled. 3. In alkalosis, the pH increases and the respiratory rate and depth decrease; CO2 is retained and car- bonic acid increases to neutralize and decrease the strength of excess bicarbonate. 4. The action of the lungs is reversible in controlling an excess or deficit. 5. The lungs can hold hydrogen ions until the deficit iscorrected orcan inactivatehydrogen ions,chang- ingthe ionsto water moleculesto be exhaled along with CO2, thus correcting the excess. 6. The process of correcting a deficit or excess takes 10 to 30 seconds to complete. 7. The lungs are capable of inactivating only hydro- gen ions carried by carbonic acid; excess hydro- gen ions created by other mechanisms must be excreted by the kidneys. Monitor the client’s respiratory status closely. In acidosis, the respiratory rate and depth increase in an attempt to exhale acids. In alkalosis, the respiratory rate and depth decrease; CO2 is retained to neutralize and decrease the strength of excess bicarbonate. D. Kidneys 1. The kidneys provide a more inclusive corrective response to acid-base disturbances than other corrective mechanisms, even though the renal excretion of acids and alkalis occurs more slowly. 2. Compensation requires a few hours to several days; however, the compensation is more thor- ough and selective than that of other regulators, such as the buffer systems and lungs. 3. In acidosis, the pH decreases and excess hydro- gen ions are secreted into the tubules and com- bine with buffers for excretion in the urine. 4. In alkalosis, the pH increases and excess bicarbonate ions move into the tubules, combine with sodium, and are excreted in the urine. 5. Selective regulation of bicarbonate occurs in the kidneys. a. The kidneys restore bicarbonate by excre- ting hydrogen ions and retaining bicarbo- nate ions. b. Excess hydrogen ions are excreted in the urine in the form of phosphoric acid. c. The alteration of certain amino acids in the renal tubules results in a diffusion of ammo- nia into the kidneys; the ammonia combines with excess hydrogen ions and is excreted in the urine. E. Potassium (K+ ) 1. Potassium plays an exchange role in maintaining acid-base balance. 2. The body changes the potassium level by draw- ing hydrogen ions into the cells or by pushing them out of the cells (potassium movement across cell membranes is facilitated by trans- cellular shifting in response to acid-base patterns). 3. The potassium level changes to compensate for hydrogen ion level changes (Fig. 9-2). a. In acidosis, the body protects itself from the acidic state by moving hydrogen ions into the cells. Therefore, potassium moves out to make room for hydrogen ions and the potas- sium level increases. b. In alkalosis, the cells release hydrogen ions into the blood in an attempt to increase the acidity of the blood; this forces the potas- sium into the cells and potassium levels decrease. When the client experiences an acid-base imbal- ance, monitor the potassium level closely because the potassium moves in or out of the cells in an attempt to maintain acid-base balance. The resulting hypokale- mia or hyperkalemia predisposes the client to associated complications. 7.35 7.45 7.80 6.80 Acidosis Normal Alkalosis Death Death 1 part carbonic acid 20 parts bicarbonate FIGURE 9-1 Acid-base balance. In the healthy state, a ratio of 1 part car- bonic acid to 20 parts bicarbonate provides a normal serum pH between 7.35 and 7.45. Any deviation to the left of 7.35 results in an acidotic state. Any deviation to the right of 7.45 results in an alkalotic state. 98 UNIT III Nursing Sciences
- 117. F u n d a m e n t a l s III. Respiratory Acidosis A. Description: The total concentration of buffer base is lower than normal, with a relative increase in hydro- gen ion concentration; thus a greater number of hydrogen ions is circulating in the blood than can be absorbed by the buffer system. B. Causes (Box 9-1) 1. Respiratory acidosis is caused by primary defects in the function of the lungs or changes in normal respiratory patterns. 2. Any condition that causes an obstruction of the airway or depresses the respiratory system can cause respiratory acidosis. If the client has a condition that causes an obstruc- tion of the airway or depresses the respiratory system, monitor the client for respiratory acidosis. C. Assessment: In an attempt to compensate, the kid- neys retain bicarbonate and excrete excess hydrogen ions into the urine (Table 9-1). D. Interventions 1. Monitor for signs of respiratory distress. 2. Administer O2 as prescribed. 3. Place the client in a semi-Fowler’s position. 4. Encourage and assist the client to turn, cough, and deep-breathe. 5. Encourage hydration to thin secretions. K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ H+ In alkalosis, more hydrogen ions are present in the intracellular fluid than in the extracellular fluid. Hydrogen ions move from the intracellular fluid into the extracellular fluid. To keep the intracellular fluid electrically neutral, potassium ions move from the extracellular fluid into the intracellular fluid, creating a relative hypokalemia. In acidosis, the extracellular hydrogen ion content increases, and the hydrogen ions move into the intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions leave the cell, creating a relative hyperkalemia. Under normal conditions, the intracellular potassium content is much greater than that of the extracellular fluid. The concentration of hydrogen ions is low in both compartments. H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ H+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ H+ H+ H+ FIGURE 9-2 Movement of potassium in response to changes in the extracellular fluid hydrogen ion concentration. BOX 9-1 Causes of Respiratory Acidosis ▪ Asthma: Spasms resulting from allergens, irritants, or emo- tions cause the smooth muscles of the bronchioles to con- strict, resulting in ineffective gas exchange. ▪ Atelectasis: Excessive mucus collection, with the collapse of alveolar sacs caused by mucous plugs, infectious drainage, or anesthetic medications, results in ineffective gas exchange. ▪ Brain trauma: Excessive pressure on the respiratorycenter or medulla oblongata depresses respirations. ▪ Bronchiectasis: Bronchi become dilated as a result ofinflam- mation, and destructive changes and weakness in the walls of the bronchi occur. ▪ Bronchitis: Inflammation causes airway obstruction, result- ing in inadequate gas exchange. ▪ Central nervous system depressants: Depressants such as sedatives, opioids, and anesthetics depress the respiratory center, leading to hypoventilation (excessive sedation from medications mayrequire reversal byopioid antagonist med- ications); carbon dioxide (CO2) is retained and the hydrogen ion concentration increases. ▪ Emphysema and COPD: Loss of elasticity of alveolar sacs restricts air flow in and out, primarily out, leading to an increased CO2 level. ▪ Administering high oxygen levels per nasal cannula to cli- ents who are CO2 retainers (i.e., emphysema and COPD). ▪ Hypoventilation: Carbon dioxide is retained and the hydro- gen ion concentration increases, leading to the acidotic state; carbonic acid is retained and the pH decreases. ▪ Pneumonia: Excess mucus production and lung congestion cause airway obstruction, resulting in inadequate gas exchange. ▪ Pulmonaryedema: Extracellular accumulation of fluid in pul- monarytissue causes disturbances in alveolar diffusion and perfusion. ▪ Pulmonary emboli: Emboli cause obstruction in a pulmo- nary artery resulting in airway obstruction and inadequate gas exchange. 99 CHAPTER 9 Acid-Base Balance
- 118. F u n d a m e n t a l s 6. Reduce restlessness by improving ventilation rather than by administering tranquilizers, seda- tives, or opioids because these medications fur- ther depress respirations. 7. Prepare to administer respiratory treatments as prescribed. 8. Suction the client’s airway, if necessary. 9. Monitor electrolyte values, particularly the potas- sium level and arterial blood gas (ABG) levels. 10. Administer antibiotics for respiratory infection or other medications as prescribed. 11. Preparefor endotrachealintubation and mechanical ventilation if CO2 levels rise above 50 mm Hg and if signs of acute respiratory distress are present. Clients withahistoryofemphysemaorchronicobstruc- tivepulmonarydisease(COPD)usuallyarenotgiven oxygen greaterthan 2liters bycannula since high levels ofoxygen in the blood maydecrease the stimulus to breathe leading to CO2 retention and respiratoryacidosis. IV. Respiratory Alkalosis A. Description: Adeficit of carbonic acid and a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. B. Causes: Respiratory alkalosis results from conditions that cause overstimulation of the respiratory system (Box 9-2). If the client has a condition that causes overstimu- lation of the respiratory system, monitor the client for respiratory alkalosis. C. Assessment: Initially the hyperventilation and respi- ratory stimulation cause abnormal rapid respirations (tachypnea); in an attempt to compensate, the kid- neys excrete excess circulating bicarbonate into the urine (Table 9-2). D. Interventions 1. Monitor for signs of respiratory distress. 2. Provide emotional support and reassurance to the client. 3. Encourage appropriate breathing patterns. 4. Assist with breathing techniques and breathing aids as prescribed. a. Encourage voluntary holding of the breath if appropriate. b. Provide use of a rebreathing mask as prescribed. c. Provide CO2 breaths as prescribed (rebreath- ing into a paper bag). 5. Provide cautious care with ventilator clients so that they are not forced to take breaths too deeply or rapidly. 6. Monitor electrolyte values, particularly potas- sium and calcium levels; monitor ABG levels. TABLE 9-1 Clinical Manifestations of Acidosis Respiratory (" PaCO2) Metabolic (#HCO3 2 ) Neurological Drowsiness Drowsiness Disorientation Confusion Dizziness Headache Headache Coma Coma Cardiovascular Decreased blood pressure Decreased blood pressure Dysrhythmias (related to hyperkalemia from compensation) Dysrhythmias (related to hyperkalemia from compensation) Warm, flushed skin (related to peripheral vasodilation) Warm, flushed skin (related to peripheral vasodilation) Gastrointestinal No significant findings Nausea, vomiting, diarrhea, abdominal pain Neuromuscular Seizures No significant findings Respiratory Hypoventilation with hypoxia (lungs are unable to compensate when there is a respiratory problem) Deep, rapid respirations (compensatory action by the lungs); known as Kussmaul’s respirations From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St. Louis, 2014, Mosby. BOX 9-2 Causes of Respiratory Alkalosis ▪ Fever: Causes increased metabolism, resulting in overstimu- lation of the respiratory system. ▪ Hyperventilation: Rapid respirations cause the blowing offof carbon dioxide (CO2), leading to a decrease in carbonic acid. ▪ Hypoxia: Stimulates the respiratory center in the brainstem, which causes an increase in the respiratory rate in order to increase oxygen (O2); this causes hyperventilation, which results in a decrease in the CO2 level. ▪ Hysteria: Often is neurogenic and related to a psychoneuro- sis; however, this condition leads to vigorous breathing and excessive exhaling of CO2. ▪ Overventilation by mechanical ventilators: The administra- tion of O2 and the depletion of CO2 can occur from mechan- ical ventilation, causing the client to be hyperventilated. ▪ Pain: Overstimulation of the respiratory center in the brain- stem results in a carbonic acid deficit. 100 UNIT III Nursing Sciences
- 119. F u n d a m e n t a l s 7. Prepare to administer calcium gluconate for tet- any as prescribed. V. Metabolic Acidosis A. Description: Atotal concentration of buffer base that is lowerthan normal,with a relativeincreasein thehydro- gen ion concentration, resulting from loss of too much base and/or retention of too much acid. B. Causes (Box 9-3) An insufficient supply of insulin in a client with diabetes mellitus can result in metabolic acidosis known as diabetic ketoacidosis. C. Assessment: To compensate for the acidosis, deep and rapid respirations, known as Kussmaul’s respira- tions, occur as the lungs attempt to exhale the excess CO2 (see Table 9-1). D. Interventions 1. Monitor for signs of respiratory distress. 2. Assess level of consciousness for central nervous system depression. 3. Monitor intake and output and assist with fluid and electrolyte replacement as prescribed. 4. Prepare to administer solutions intravenously as prescribed to increase the buffer base. 5. Initiate safety and seizure precautions. 6. Monitor the ABG levels and the potassium level closely; as metabolic acidosis resolves, potassium moves back into the cells and the potassium level decreases. E. Interventions in diabetes mellitus and diabetic ketoacidosis 1. Give insulin as prescribed to hasten the move- ment of glucose into the cells, thereby decreasing the concurrent ketosis. 2. When glucose is being properly metabolized, the body will stop converting fats to glucose. 3. Monitor for circulatory collapse caused by poly- uria, which may result from the hyperglycemic state; osmotic diuresis may lead to extracellular volume deficit. Monitor the client experiencing severe diarrhea for manifestations of metabolic acidosis. F. Interventions in kidney disease 1. Dialysis maybe used to remove protein and waste products, thereby lessening the acidotic state. 2. A diet low in protein and high in calories decreases the amount of protein waste products, which in turn lessens the acidosis. VI. Metabolic Alkalosis A. Description: A deficit of carbonic acid and a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid TABLE 9-2 Clinical Manifestations of Alkalosis Respiratory (#PaCO2) Metabolic (" HCO3 2 ) Neurological Lethargy Drowsiness Lightheadedness Dizziness Confusion Nervousness Confusion Cardiovascular Tachycardia Tachycardia Dysrhythmias (related to hypokalemia from compensation) Dysrhythmias (related to hypokalemia from compensation) Gastrointestinal Nausea Anorexia Vomiting Nausea Epigastric pain Vomiting Neuromuscular Tetany Tremors Numbness Hypertonic muscles Tingling of extremities Muscle cramps Hyperreflexia Tetany Seizures Tingling of extremities Seizures Respiratory Hyperventilation (lungs are unable to compensate when there is a respiratory problem) Hypoventilation (compensatory action by the lungs) From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St. Louis, 2014, Mosby. BOX 9-3 Causes of Metabolic Acidosis ▪ Diabetes mellitus or diabetic ketoacidosis: An insufficient supplyof insulin causes increased fat metabolism, leading to an excess accumulation of ketones or other acids; the bicarbonate then ends up being depleted. ▪ Excessive ingestion of acetylsalicylic acid: Causes an increase in the hydrogen ion concentration. ▪ High-fat diet: Causes a much too rapid accumulation ofthe waste products of fat metabolism, leading to a buildup of ketones and acids. ▪ Insufficient metabolism of carbohydrates: When the oxy- gen supplyis not sufficient for the metabolism of carbohy- drates, lactic acid is produced and lactic acidosis results. ▪ Malnutrition: Improper metabolism of nutrients causes fat catabolism,leadingto an excess buildupofketones andacids. ▪ Renal insufficiency, acute kidney injury, or chronic kidney disease: Increased waste products of protein metabolism are retained; acids increase, and bicarbonate is unable to maintain acid-base balance. ▪ Severe diarrhea: Intestinal and pancreatic secretions are normally alkaline; therefore, excessive loss of base leads to acidosis. 101 CHAPTER 9 Acid-Base Balance
- 120. F u n d a m e n t a l s without a comparable loss of base in the body fluids. B. Causes: Metabolic alkalosis results from a dysfunc- tion of metabolism that causes an increased amount of available base solution in the blood or a decrease in available acids in the blood (Box 9-4). C. Assessment: To compensate, respiratory rate and depth decrease to conserve CO2 (see Table 9-2). Monitor the client experiencing excessive vomiting or the client with gastrointestinal suctioning for manifes- tations of metabolic alkalosis. D. Interventions 1. Monitor for signs of respiratory distress. 2. Monitor ABGs and potassium and calcium levels. 3. Institute safety precautions. 4. Prepare to administer medications and intrave- nous fluids as prescribed to promote the kidney excretion of bicarbonate. 5. Prepare to replace potassium as prescribed. 6. Treat the underlying cause of the alkalosis. VII. Arterial Blood Gases (ABGs) (Table 9-3) A. Collection of an ABG specimen 1. Obtain vital signs. 2. Determine whether the client has an arterial line in place (allows for arterial blood sampling with- out further puncture to the client). 3. Perform the Allen’s test to determine the presence of collateral circulation (see Priority Nursing Actions). PRIORITYNURSING ACTIONS Performing the Allen’s Test Before Radial Artery Puncture 1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries simultaneously. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar arterywhile compressing the radial artery. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings. The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the pres- ence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence ofadequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client.To per- form the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While applying pres- sure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial arteryand assesses the color ofthe extremitydistalto the pres- sure point. Ifpinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Other sites, such as the brachial or femoral artery, can be used if the radial artery is not deemed adequate. Reference Perry, Potter, Ostendorf (2014), pp. 1091–1092. 4. Assess factors that may affect the accuracy of the results, such as changes in the O2 settings, suc- tioning within the past 20 minutes, and client’s activities. 5. Provide emotional support to the client. 6. Assist with the specimen draw; prepare a hepa- rinized syringe (if not already prepackaged). 7. Apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes or for 10 minutes if the client is taking an anticoagulant. 8. Appropriately label the specimen and transport it on ice to the laboratory. 9. On the laboratory form, record the client’s tem- perature and the type of supplemental O2 that the client is receiving. BOX 9-4 Causes of Metabolic Alkalosis ▪ Diuretics: The loss of hydrogen ions and chloride from diuresis causes a compensatory increase in the amount of bicarbonate in the blood. ▪ Excessive vomiting or gastrointestinal suctioning: Leads to an excessive loss of hydrochloric acid. ▪ Hyperaldosteronism: Increased renal tubular reabsorption of sodium occurs, with the resultant loss of hydrogen ions. ▪ Ingestion of and/or infusion of excess sodium bicarbon- ate: Causes an increase in the amount of base in the blood. ▪ Massivetransfusion ofwholeblood:The citrateanticoagulant used for the storage of blood is metabolized to bicarbonate. TABLE 9-3 Normal Arterial Blood Gas Values Normal Range Laboratory Test Conventional Units SI Units pH 7.35-7.45 7.35-7.45 PaCO2 35-45 mm Hg 35-45 mm Hg Bicarbonate (HCO3 À ) 21-28 mEq/L 21-28 mmol/L PaO2 80-100 mm Hg 80-100 mm Hg kPa, Kilopascal; mmol, millimole (10À3 mole); PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood. Note: Because arterial blood gases are influenced by altitude, the value for PaO2 decreases as altitude increases. 102 UNIT III Nursing Sciences
- 121. F u n d a m e n t a l s B. Respiratory acid-base imbalances (Table 9-4) 1. Remember that the respiratory function indica- tor is the PaCO2. 2. In a respiratory imbalance, you will find an opposite relationship between the pH and the PaCO2; in other words, the pH will be elevated with a decreased PaCO2 (alkalosis) or the pH will be decreased with an elevated PaCO2 (acidosis). 3. Look at the pH and the PaCO2 to determine whether the condition is a respiratory problem. 4. Respiratory acidosis: The pH is decreased; the PaCO2 is elevated. 5. Respiratory alkalosis: The pH is elevated; the PaCO2 is decreased. C. Metabolic acid-base imbalances (see Table 9-4) 1. Remember, the metabolic function indicator is the bicarbonate ion (HCO3 À ). 2. In a metabolic imbalance, there is a correspond- ing relationship between the pH and the HCO3 À ; in other words, the pH will be elevated and HCO3 À will be elevated (alkalosis), or the pH will be decreased and HCO3 À will be decreased (acidosis). 3. Look at the pH and the HCO3 À to determine whether the condition is a metabolic problem. 4. Metabolic acidosis: The pH is decreased; the HCO3 À is decreased. 5. Metabolic alkalosis: The pH is elevated; the HCO3 À is elevated. In a respiratoryimbalance, the ABG result indicates an opposite relationship between the pH and the PaCO2. In a metabolic imbalance, the ABG result indicates a cor- responding relationship between the pH and the HCO3 À . D. Compensation (see Table 9-4) 1. Compensation refers to the body processes that occur to counterbalancethe acid-basedisturbance. 2. When full compensation has occurred, the pH is within normal limits. E. Steps for analyzing ABG results (Box 9-5) F. Mixed acid-base disorders 1. Occurs when 2 or more disorders are present at the same time. 2. The pH will depend on the type and severity of the disorders involved, including any compensa- tory mechanisms at work, e.g., respiratory acido- sis combined with metabolic acidosis will result in a greater decrease in pH than either imbalance occurring alone. 3. Example: Mixed alkalosis can occur if a client begins to hyperventilate due to postoperative pain (respiratoryalkalosis) and isalso losingacid dueto gastric suctioning (metabolic alkalosis). CRITICALTHINK ING W hat Should Y ou Do? Answer: Failure to determine the presence of adequate col- lateral circulation before drawing an arterial blood gas spec- imen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar arteryis insufficient, indicating that the radial arteryshould not be used for obtain- ing a blood specimen. Another site needs to be selected for the arterial puncture and the health care provider needs to be notified of the finding. Reference: Perry, Potter, Ostendorf (2014), p. 1091. TABLE 9-4 Acid-Base Imbalances: Usual Laboratory Value Changes Imbalance pH HCO3 À PaO2 PaCO2 K+ Respiratory acidosis U: Decreased PC: Decreased C: Normal U: Normal PC: Increased C: Increased Usually decreased U: Increased PC: Increased C: Increased Increased Respiratory alkalosis U: Increased PC: Increased C: Normal U: Normal PC: Decreased C: Decreased Usually normal but depends on other accompanying conditions U: Decreased PC: Decreased C: Decreased Decreased Metabolic acidosis U: Decreased PC: Decreased C: Normal U: Decreased PC: Decreased C: Decreased Usually normal but depends on other accompanying conditions U: Normal PC: Decreased C: Decreased Increased Metabolic alkalosis U: Increased PC: Increased C: Normal U: Increased PC: Increased C: Increased Usually normal but depends on other accompanying conditions U: Normal PC: Increased C: Increased Decreased U, uncompensated; PC, partially compensated; C, compensated. 103 CHAPTER 9 Acid-Base Balance
- 122. F u n d a m e n t a l s P RACTI CE Q U ES TI O N S 53. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mm Hg (30 mm Hg), and HCO3 À of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated 54. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse mon- itors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 55. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) moni- tor displays tachycardia, with a heart rate of120 beats/ minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PaCO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3 À 4. An increased pH and an increased HCO3 À 56. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH ¼7.53, PaO2 ¼72 mm Hg (72 mm Hg), PaCO2 ¼32 mm Hg (32 mm Hg), and HCO3 À ¼28 mEq/L(28 mmol/L). Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating. 57. The nurse is caring for a client with diabetic ketoaci- dosis and documents that the client is experiencing Kussmaul’s respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds 58. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90 mm Hg (90 mm Hg), and HCO3 À is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation BOX 9-5 Analyzing Arterial Blood Gas Results If you can remember the following Pyramid Points and Pyramid Steps, you will be able to analyze any blood gas report. Pyramid Points In acidosis, the pH is decreased. In alkalosis, the pH is elevated. The respiratory function indicator is the PaCO2. The metabolic function indicator is the bicarbonate ion (HCO3 À ). Pyramid Steps Pyramid Step 1 Look at the blood gas report. Look at the pH. Is the pH elevated or decreased? Ifthe pH is elevated, it reflects alkalosis. Ifthe pH is decreased, it reflects acidosis. Pyramid Step 2 Look at the PaCO2. Is the PaCO2 elevated or decreased? If the PaCO2 reflects an opposite relationship to the pH, the condition is a respiratoryimbalance. If the PaCO2 does not reflect an oppo- site relationship to the pH, go to Pyramid Step 3. Pyramid Step 3 Look at the HCO3 À . Does the HCO3 À reflect a corresponding relationship with the pH? If it does, the condition is a metabolic imbalance. Pyramid Step 4 Fullcompensation has occurred ifthe pH is in a normal range of 7.35 to 7.45. If the pH is not within normal range, look at the respiratory or metabolic function indicators. If the condition is a respiratory imbalance, look at the HCO3 À to determine the state of compensation. If the condition is a metabolic imbalance, look at the PaCO2 to determine the state of compensation. 104 UNIT III Nursing Sciences
- 123. F u n d a m e n t a l s 59. The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness 60. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respi- ratory acidosis. Which result validates the nurse’s findings? 1. pH 7.25, PaCO2 50 mm Hg (50 mm Hg) 2. pH 7.35, PaCO2 40 mm Hg (40 mm Hg) 3. pH 7.50, PaCO2 52 mm Hg (52 mm Hg) 4. pH 7.52, PaCO2 28 mm Hg (28 mm Hg) 61. The nurse is caring for a client who is on a mechan- ical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L (145 mmol/L) 2. Potassium level of 3.0 mEq/L (3.0 mmol/L) 3. Magnesium level of 1.3 mEq/L (0.65 mmol/L) 4. Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 62. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics con- taining base products AN S WERS 53. 2 Rationale: The normal pH is 7.35 to 7.45. In a respiratory con- dition, an opposite effect will be seen between the pH and the PaCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indi- cate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred. Test-Taking Strategy: Focus on the subject, arterial blood gas results. Remember that in a respiratory imbalance you will find an opposite response between the pH and the PCO2 as indicated in the question. Therefore, you can eliminate the options reflective of a primary metabolic problem. Also, remember that the pH increases in an alkalotic condition and compensation can be evidenced by a normal pH. The correct option reflects a respiratory alkalotic condition and compensation and describes the blood gas values as indicated in the question. Review: The steps related to analyzing arterial blood gas results and the findings noted in respiratory alkalosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), p. 304. 54. 2 Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gas- tric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations. Test-Taking Strategy: Focus on the subject, a client with a nasogastric tube attached to suction. Remembering that a client receiving nasogastric suction loses hydrochloric acid will direct you to the option identifying an alkalotic condition. Because the question addresses a situation other than a respiratory one, the acid-base disorder would be a metabolic condition. Review: The causes of metabolic alkalosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), pp. 304–305. 55. 4 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 À to increase. Symptoms experienced by the client would include hypoventi- lation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition. Test-Taking Strategy: Focus on the subject, expected arterial blood gas findings. Note the data in the question and that the client is vomiting. Recalling that vomiting most likely causes metabolic alkalosis will assist in directing you to the cor- rect option. Review: The causes of metabolic alkalosis Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment 105 CHAPTER 9 Acid-Base Balance
- 124. Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment References: Ignatavicius, Workman (2016), pp. 183–184; Lewis et al. (2014), pp. 303–305. 56. 4 Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclu- sion can be made about a client’s fluid volume status from the information provided. Test-Taking Strategy: Focus on the data in the question. Note the ABG values and use knowledge to interpret them. Note that the pH is elevated and the PaCO2 is decreased from normal. This will assist you in determining that the client is experiencing respiratory alkalosis. Next, think about the causes of respiratory alkalosis to answer correctly. Review: The causes of respiratory alkalosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), pp. 304–305. 57. 2, 4 Rationale: Kussmaul’s respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds. Test-Taking Strategy: Focus on the subject, the characteristics of Kussmaul’s respirations. Use knowledge of the description of Kussmaul’s respirations. Recalling that this type of respira- tion occurs in diabetic ketoacidosis will assist you in answering correctly. Review: The characteristics of Kussmaul’s respirations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Perry, Potter, Ostendorf (2014), p. 89. 58. 4 Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respi- ratory acidosis the pH is decreased and the PCO2 is elevated. The normal bicarbonate (HCO3 À ) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid- base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations. Test-Taking Strategy: Focus on the subject, interpretation of arterial blood gas results. Remember that in a respiratory imbalance you will find an opposite response between the pH and the PaCO2. Also, remember that the pH is decreased in an acidotic condition and that compensation is reflected by a normal pH. Review: The procedure for analyzing blood gas results Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), p. 304. 59. 1, 2, 4, 6 Rationale: Respiratory alkalosis is defined as a deficit of car- bonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respira- tory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dys- rhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperven- tilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associ- ated with acidosis. Test-Taking Strategy: Focus on the subject, the interpretation of ABG values. Note the data in the question to determine that the client is experiencing respiratory alkalosis. Next, it is neces- sary to think about the pathophysiology that occurs in this con- dition and recall the manifestations that occur. Review: The clinical manifestations of respiratory alkalosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), p. 305. 60. 1 Rationale: Atelectasis is a condition characterized by the col- lapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the PaCO2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 iden- tifies respiratory alkalosis. Test-Taking Strategy: Focus on the subject, the arterial blood gas results in a client with atelectasis. Remember that in a respi- ratory imbalance you will find an opposite response between the pH and the PaCO2. Also, remember that the pH is decreased in an acidotic condition. First eliminate option 2 because it reflects a normal blood gas result. Options 3 and 4 identify an elevated pH, indicating an alkalotic condition. The correct option is the only one that reflects an acidotic condition. Review: Blood gas findings in respiratory acidosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), pp. 305, 550. F u n d a m e n t a l s 106 UNIT III Nursing Sciences
- 125. 61. 2 Rationale: Respiratory alkalosis is defined as a deficit of car- bonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respira- tory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dys- rhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The cor- rect option identifies the presence of hypokalemia. Test-Taking Strategy: Note the strategic words, most likely. Focus on the data in the question and use knowledge about the interpretation of arterial blood gas values to determine that the client is experiencing respiratory alkalosis. Next, recall the manifestations that occur in this condition and the normal lab- oratory values. The only abnormal laboratory value is the potassium level, the correct option. Review: The clinical manifestations of respiratory alkalosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), p. 305. 62. 1 Rationale: Respiratory acidosis is most often caused by hypo- ventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incor- rect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products. Test-Taking Strategy: Focus on the data in the question. Think about the location of the ribs to determine that the client will have difficulty breathing adequately. This will assist in directing you to the correct option. Remembering that hypo- ventilation results in respiratory acidosis will direct you to the correct option. Review: Causes of respiratory acidosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Acid-Base Priority Concepts: Acid-Base Balance; Clinical Judgment Reference: Lewis et al. (2014), pp. 305, 598. F u n d a m e n t a l s 107 CHAPTER 9 Acid-Base Balance
- 126. F u n d a m e n t a l s CH AP TER 10 Vital Signs and Laboratory Reference Intervals PRIORITYCONCEPTS Cellular Regulation; Perfusion CRITICALTHINK ING W hat Should Y ou Do? The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client’s vital signs. On arrival to the unit, the client’s temperature was 37.2 °C (98.9 °F) orally, the blood pressure was 142/78 mm Hg, the heart rate was 98 beats per minute, the respiratory rate was 14 breaths per minute, and the oxygen saturation was 95% on 3 L of oxygen via nasal cannula. The nurse returns to the room 30 minutes later to find the client’s temperature to be 36.8 °C (98.2 °F) orally, the blood pressure 95/54 mm Hg, the heart rate 118 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 92% on 3 L of oxygen via nasal cannula. On the basis of these data, what actions should the nurse take? Answer located on p. 119. I. Vital Signs A. Description: Vital signs include temperature, pulse, respirations, blood pressure (BP), oxygen saturation (pulse oximetry), and pain assessment. B. Guidelines for measuring vital signs 1. Initial measurement of vital signs provides base- line data on a client’s health status and is used to help identify changes in the client’s health status. 2. Some vital sign measurements (temperature, pulse, respirations, BP, pulse oximetry) may be delegated to unlicensed assistive personnel (UAP), but the nurse is responsible for interpret- ing the findings. 3. The nurse collaborates with the health care pro- vider (HCP) in determining the frequency of vital sign assessment and also makes indepen- dent decisions regarding their frequency on the basis of the client’s status. The nurse always documents vital sign measure- ments and reports abnormal findings to the HCP. C. When vital signs are measured 1. On initial contact with a client (e.g., when a cli- ent is admitted to a health care facility) 2. During physical assessment of a client 3. Before and after an invasive diagnostic procedure or surgical procedure 4. During the administration of medication that affects the cardiac, respiratory, or temperature- controlling functions (e.g., in a client who has a fever); may be required before, during, and after administration of the medication 5. Before, during, and after a blood transfusion 6. Whenever a client’s condition changes 7. Whenever an intervention (e.g., ambulation) may affect a client’s condition 8. When a fever or known infection is present (every 2 to 4 hours) II. Temperature A. Description 1. Normal body temperature ranges from 36.4° to 37.5° Celsius (C) (97.5° to 99.5° Fahrenheit [F]); the average in a healthy young adult is 37.0 °C (98.6 °F). 2. Common measurement sites are the mouth, rec- tum, axilla, ear, and across the forehead (tempo- ral artery site); various types of electronic measuring devices are commonly used. 3. Rectal temperatures are usually 1 °F (0.5 °C) higher and axillary temperatures about 1 °F (0.5 °C) lower than the normal oral temperature. 4. Know how to convert a temperature to a Fahren- heit or Celsius value (Box 10-1). B. Nursing considerations 1. Time of day a. Temperature is generally in the low-normal range at the time of awakening as a result of muscle inactivity. b. Afternoon body temperature may be high- normal as a result of the metabolic process, activity, and environmental temperature. 108
- 127. 2. Environmental temperature: Body temperature is lower in cold weather and higher in warm weather. 3. Age: Temperature may fluctuate during the first year of life because the infant’s heat-regulating mechanism is not fully developed. 4. Physical exercise: Use of the large muscles creates heat, causing an increase in body temperature. 5. Menstrual cycle: Temperature decreases slightly just before ovulation but may increase to 1 °F above normal during ovulation. 6. Pregnancy: Body temperature may consistently stay at high-normal because of an increase in the woman’s metabolic rate. 7. Stress: Emotions increase hormonal secretion, leading to increased heat production and a higher temperature. 8. Illness: Infective agents and the inflammatory response may cause an increase in temperature. 9. The inability to obtain a temperature should not be ignored because it could represent a condition of hypothermia, a life-threatening condition in very young and older clients. C. Methods of measurement 1. Oral a. If the client has recently consumed hot or cold foods or liquids or has smoked or chewed gum, the nurse must wait 15 to 30 minutes before taking the temperature orally. b. The thermometer is placed under the tongue in 1 ofthe posterior sublingual pockets;ask the cli- ent to keep the tongue down and the lips closed and to not bite down on the thermometer. 2. Rectal a. Place the client in the Sims position. b. The temperature is taken rectally when an accurate temperature cannot be obtained orally or when the client has nasal conges- tion, has undergone nasal or oral surgery or had the jaws wired, has a nasogastric tube in place, is unable to keep the mouth closed, or is at risk for seizures. c. The thermometer is lubricated and inserted into the rectum, toward the umbilicus, about 1.5 inches (3.8 cm) (no more than 0.5 inch [1.25 cm] in an infant). The temperature is not taken rectally in cardiac cli- ents; the client who has undergone rectal surgery; or the client with diarrhea, fecalimpaction, or rectal bleeding or who is at risk for bleeding. 3. Axillary a. This method of taking the temperature is used when the oral or rectal temperature measure- ment is contraindicated. b. Axillary measurement is not as accurate as the oral, rectal, tympanic, or temporal artery method but is used when other methods of measurement are not possible. c. The thermometer is placed in the client’s dry axilla and the client is asked to hold the arm tightly against the chest, resting the arm on the chest; follow the instructions accompany- ing the measurement device for the amount of time the thermometer should remain in the axillary area. 4. Tympanic a. The auditory canal is checked for the presence of redness, swelling, discharge, or a foreign body before the probe is inserted; the probe should not be inserted if the client has an inflammatory condition of the auditory canal or if there is discharge from the ear. b. The reading may be affected by an ear infec- tion or excessive wax blocking the ear canal. 5. Temporal artery a. Ensure that the client’s forehead is dry. b. The thermometer probe is placed flush against the skin and slid across the forehead or placed in the area of the temporal artery and held in place. c. If the client is diaphoretic, the temporal artery thermometer probe may be placed on the neck, just behind the earlobe. III. Pulse A. Description 1. The average adult pulse (heart) rate is 60 to 100 beats/min. 2. Changes in pulse rate are used to evaluate the cli- ent’s tolerance of interventions such as ambula- tion, bathing, dressing, and exercise. 3. Pedal pulses are checked to determine whether the circulation is blocked in the artery up to that pulse point. 4. When the pedal pulse is difficult to locate, a Doppler ultrasound stethoscope (ultrasonic stethoscope) may be needed to amplify the sounds of pulse waves. B. Nursing considerations 1. The heart rate slows with age. 2. Exercise increases the heart rate. 3. Emotions stimulate the sympathetic nervous sys- tem, increasing the heart rate. F u n d a m e n t a l s BOX 10-1 Body Temperature Conversion To convert Fahrenheit to Celsius: Degrees Fahrenheit – 32 5/9 ¼Degrees Celsius Example: 98.2 °F – 32 5/9 ¼36.7 °C To convert Celsius to Fahrenheit: Degrees Celsius  9/5 +32¼Degrees Fahrenheit Example: 38.6 °C 9/5+32¼101.5 °F 109 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 128. 4. Pain increases the heart rate. 5. Increased body temperature causes the heart rate to increase. 6. Stimulant medications increase the heart rate; depressants and medications affecting the car- diac system slow it. 7. When the BP is low, the heart rate is usually increased. 8. Hemorrhage increases the heart rate. C. Assessing pulse qualities 1. When the pulse is being counted, note the rate, rhythm, and strength (force or amplitude). 2. Once you have checked these parameters, use the grading scale for pulses to assess the information you have elicited (Box 10-2). D. Pulse points and locations 1. The temporal artery can be palpated anterior to or in the front of the ear. 2. The carotid artery is located in the groove between the trachea and the sternocleidomas- toid muscle, medial to and alongside the muscle. 3. The apical pulse may be detected at the left mid- clavicular, fifth intercostal space. 4. The brachial pulse is located above the elbow at the antecubital fossa, between the biceps and tri- ceps muscles. 5. The radial pulse is located in the groove along the radial or thumb side of the client’s inner wrist. 6. The femoral pulse is located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine. 7. The popliteal pulse is located behind the knee. 8. The posterior tibial pulse is located on the inner side of the ankle, behind and below the medial malleolus (ankle bone). 9. The dorsalis pedis pulse is located on the top of the foot, in line with the groove between the extensor tendons of the great and first toes. The apical pulse is counted for 1 full minute and is assessed in clients with an irregular radial pulse or a heart condition, before the administration of cardiac medications such as digoxin and beta blockers, and in children younger than 2 years. E. Pulse deficit 1. In this condition, the peripheral pulse rate (radial pulse) is less than the ventricular contrac- tion rate (apical pulse). 2. Apulse deficit indicates a lack of peripheral perfu- sion;can be an indication ofcardiacdysrhythmias. 3. One-examiner technique: Auscultate and count the apical pulse first and then immediately count the radial pulse. 4. Two-examiner technique: One person counts the apical pulse and the other counts the radial pulse simultaneously. 5. Apulse deficit indicates that cardiac contractions are ineffective, failing to send pulse waves to the periphery. 6. If a difference in pulse rate is noted, the HCP is notified. IV. Respirations A. Description 1. Respiratory rates vary with age. 2. The normal adult respiratory rate is 12 to 20 breaths/min. B. Nursing considerations 1. Many of the factors that affect the pulse rate also affect the respiratory rate. 2. An increased level of carbon dioxide or a lower level of oxygen in the blood results in an increase in respiratory rate. 3. Head injuryor increased intracranial pressure will depress the respiratory center in the brain, result- ing in shallow respirations or slowed breathing. 4. Medications such as opioid analgesics depress respirations. C. Assessing respiratory rate 1. Count the client’s respirations after measuring the radial pulse. (Continue holding the client’s wrist while counting the respirations or position the hand on the client’s chest.) 2. One respiration includes both inspiration and expiration. 3. The rate, depth, pattern, and sounds are assessed. The respiratory rate maybe counted for 30 seconds and multiplied by2, except in a client who is known to be very ill or is exhibiting irregular respirations, in which case respirations are counted for 1 full minute. V. Blood Pressure A. Description 1. BP is the force on the walls of an artery exerted by the pulsating blood under pressure from the heart. 2. The heart’s contraction forces blood under high pressure into the aorta; the peak of maximum pressure when ejection occurs is the systolic pres- sure; the blood remaining in the arteries when the ventricles relax exerts a force known as the diastolic pressure. 3. The difference between the systolic and diastolic pressures is called the pulse pressure. F u n d a m e n t a l s BOX 10-2 Grading Scale for Pulses 4+¼Strong and bounding 3+¼Full pulse, increased 2+¼Normal, easily palpable 1+¼Weak, barely palpable 0 ¼Absent, not palpable 110 UNIT III Nursing Sciences
- 129. 4. For an adult (age 18 and older), a normal BP is a systolic pressure below 120 mm Hg and a dia- stolic pressure below 80 mm Hg. 5. Classifications include prehypertension and stage 1 and stage 2 hypertension (Box 10-3). 6. In postural (orthostatic) hypotension, a normo- tensive client exhibits symptoms and low BP on rising to an upright position. 7. To obtain orthostatic vital sign measurements, check the BP and pulse with the client supine, sit- ting, and standing; readings are obtained 1 to 3 minutes after the client changes position. B. Nursing considerations 1. Factors affecting BP a. BP tends to increase as the aging process progresses. b. Stress results in sympathetic stimulation that increases the BP. c. The incidence of high BP is higher among African Americans than among Americans of European descent. d. Antihypertensive medications and opioid analgesics can decrease BP. e. BP is typically lowest in the early morning, gradually increases during the day, and peaks in the late afternoon and evening. f. After puberty, males tend to have higher BP than females; after menopause, women tend to have higher BP than men of the same age. 2. Guidelines for measuring BP a. Determine the best site for assessment. b. Avoid applying a cuff to an extremity into which intravenous (IV) fluids are infusing, where an arteriovenous shunt or fistula is present, on the side on which breast or axil- lary surgery has been performed, or on an extremity that has been traumatized or is diseased. c. The leg may be used if the brachial artery is inaccessible; the cuff is wrapped around the thigh and the stethoscope is placed over the popliteal artery. d. Ensure that the client has not smoked or exer- cised in the 30 minutes before measurement because both activities can yield falsely high readings. e. Have the client assume a sitting (with feet flat on floor) or lying position and then rest for 5 minutes before the measurement; ask the client not to speak during the measurement. f. Ensure that the cuff is fully deflated, then wrap it evenly and snugly around the extremity. g. Ensure that the stethoscope being used fits the examiner and does not impair hearing. h. Document the first Korotkoff sound at phase 1 (heard as the blood pulsates through the vessel when air is released from the BP cuff and pressure on the artery is reduced) as the systolic pressure and the beginning of the fifth Korotkoff sound at phase 5 as the dia- stolic pressure. i. BP readings obtained electronically with a vital sign monitoring machine should be checked with a manual cuff if there is any con- cern about the accuracy of the reading. When taking a BP, select the appropriate cuff size; a cuff that is too small will yield a falsely high reading, and a cuff that is too large will yield a falsely low one. VI. Pulse Oximetry A. Description 1. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s hemoglobin. 2. The capillary oxygen saturation (SaO2) is recorded as a percentage. 3. The normal value is 95% to 100%. 4. After a hypoxic client uses up the readily avail- able oxygen (measured as the arterial oxygen pressure, PaO2, on arterial blood gas [ABG] test- ing), the reserve oxygen, that oxygen attached to the hemoglobin (SaO2), is drawn on to pro- vide oxygen to the tissues. 5. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur. 6. If pulse oximetry readings are below normal, instruct the client in deep breathing technique and recheck the pulse oximetry. B. Procedure 1. Asensor is placed on the client’s finger, toe, nose, earlobe, or forehead to measure oxygen satura- tion, which then is displayed on a monitor. 2. Maintain the transducer at heart level. 3. Do not select an extremity with an impediment to blood flow. Ausual pulse oximetryreading is between 95% and 100%. A pulse oximetry reading lower than 90% neces- sitates HCP notification; values below 90% are accept- able only in certain chronic conditions. Agency procedures and HCP prescriptions are followed regard- ing actions to take for specific readings. F u n d a m e n t a l s BOX 10-3 Hypertension Classifications Prehypertension: A systolic blood pressure (BP) of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg Stage 1: Asystolic BP of 140 to 159 mm Hg or a diastolic pres- sure of 90 to 99 mm Hg Stage 2: Asystolic BP equal to or greater than 160 mm Hg or a diastolic pressure equal to or greater than 100 mm Hg 111 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 130. F u n d a m e n t a l s VII. Pain A. Types of pain 1. Acute: Usually associated with an injury, medical condition, or surgical procedure; lasts hours to a few days 2. Chronic: Usually associated with long-term or chronic illnesses or disorders; may continue for months or even years 3. Phantom: Occurs after the loss of a body part (amputation); may be felt in the amputated part for years after the amputation B. Assessment 1. Pain is a highly individual experience. 2. Ask the client to describe pain in terms of degree, quality, area, and frequency. 3. Ask the client about the use of complementary and alternative therapies to alleviate pain. 4. Pain experienced by the older client may be man- ifested differently than pain experienced by members of other age groups (e.g., sleep distur- bances, changes in gait and mobility, decreased socialization, depression). 5. Clients with cognitive disorders (e.g., a client with dementia, a comatose client) may not be able to describe their pain experiences. 6. The nurse should be alert to nonverbal indicators of pain (Box 10-4). 7. Ask the client to use a number-based pain scale (a picture-based scale may be used in children or clients who cannot verbally describe their pain) to rate the degree of pain (Fig. 10-1). 8. Evaluate client response to nonpharmacological interventions. Consider the client’s culture in assessing pain; some cultures, including many Asian cultures, frown on the outward expression of pain. C. Conventional nonpharmacological interventions 1. Cutaneous stimulation a. Techniques include heat, cold, and pressure and vibration. Therapeutic touch and massage are also cutaneous stimulation and may be considered complementary and alternative techniques. b. Such treatments may require an HCP’s prescription. 2. Transcutaneous electrical nerve stimulation (TENS) a. TENS is also referred to as percutaneous elec- trical nerve stimulation (PENS). b. This technique, which may require an HCP’s prescription, involves the application of a battery-operated device that delivers a low electrical current to the skin and underlying tissues to block pain. 3. Binders, slings, and other supportive devices a. Cloths or other materials or devices, wrapped around a limb or body part, can ease the pain of strains, sprains, and surgical incisions. b. Such devicesmayrequirean HCP’sprescription. c. Elevation of the affected body part is another intervention that can reduce swelling; sup- porting an extremity on a pillow may lessen discomfort. 4. Heat and cold a. The application of heat and cold or alternat- ing application of the two can soothe pain resulting from muscle strain. b. Such treatment may require an HCP’s pre- scription. BOX 10-4 Nonverbal Indicators of Pain ▪ Moaning ▪ Crying ▪ Irritability ▪ Restlessness ▪ Grimacing or frowning ▪ Inability to sleep ▪ Rigid posture ▪ Increased blood pressure, heart rate, or respiratory rate ▪ Nausea ▪ Diaphoresis 0 No hurt 1 or 2 Hurts little bit 2 or 4 Hurts little more 3 or 6 Hurts even more 4 or 8 Hurts whole lot 5 or 10 Hurts worst B A No pain 0 1 2 3 4 5 6 7 8 9 10 Severe pain Numerical Des criptive No pain Mild pain Moderate pain Unbearable pain Severe pain Vis ual analog No pain Unbearable pain Clients designate a point on the scale corresponding to their perception of the pain’s severity at the time of assessment. FIGURE 10-1 Pain assessment scales. A, Numerical, descriptive, and visual analog scales. B, Wong-Baker FACES® Pain Rating Scale. (B, Copy- right 1983, Wong-Baker FACES® Foundation, www.WongBakerFACES.org. Used with permission. Originally published in Whaley &Wong’s Nursing Care of Infants and Children. ©Elsevier Inc.) 112 UNIT III Nursing Sciences
- 131. c. Heat applications may include warm-water compresses, warm blankets, thermal pads, and tub and whirlpool baths. d. The temperature of the application must be monitored carefully to help prevent burns; the skin of very young and older clients is extra sensitive to heat. e. The application of cold can reduce swelling and muscle spasms and ease pain in joints and muscles. f. The client should be advised to remove the source of heat or cold if changes in sensation or discomfort occur. If the change in sensa- tion or discomfort is not relieved after removal of the application, the HCP should be notified. Ice or heat should be applied with a towel or other barrier between the pack and the skin, but should not be left in place for more than 15 to 30 minutes. D. Complementary and alternative therapies 1. Description: Therapies are used in addition to conventional treatment to provide healing resources and focus on the mind-body connec- tion (Box 10-5). 2. Nursing considerations a. Some complementary and alternative thera- pies require an HCP’s prescription. b. Herbal remedies are considered pharmaco- logical therapy by some HCPs; because of the risk for interaction with prescription med- ications, it is important that the nurse ask the client about the use of such therapies. c. If spiritual measures are to be employed, the nurse must elicit from the client the preferred forms of spiritual expression and learn when they are practiced so that they may be inte- grated into the plan of care. VIII. Pharmacological Interventions A. Nonopioid analgesics 1. Nonsteroidal antiinflammatory drugs (NSAIDs) and acetylsalicylic acid (Aspirin) (Box 10-6) a. These medication types are contraindicated if the client has gastric irritation or ulcer disease or an allergy to the medication. b. Bleeding is a concern with the use of these medication types. c. Instruct the client to take oral doses with milk or a snack to reduce gastric irritation. d. NSAIDs can amplify the effects of anticoagulants. e. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent. f. Ahigh risk of toxicity exists if the client is tak- ing ibuprofen concurrently with a calcium channel blocker. 2. Acetaminophen a. Acetaminophen, commonly known as Tyle- nol, is contraindicated in clients with hepatic or renaldisease,alcoholism, or hypersensitivity. b. Assess the client for a history of liver dys- function. c. Monitor the client for signs of hepatic damage (e.g., nausea and vomiting, diarrhea, abdominal pain). d. Monitor liver function parameters. e. Tell the client that self-medication should not continue longer than 10 days in an adult or 5 days in a child because of the risk of hepatotoxicity. f. The antidote to acetaminophen is acetylcys- teine. F u n d a m e n t a l s BOX 10-5 Complementary and Alternative Therapies Acupuncture and acupressure Biofeedback Chiropractic manipulation Distraction techniques Guided imagery and meditation techniques Herbal therapies Hypnosis Laughter and humor Massage Relaxation and repositioning techniques Spiritual measures (e.g., prayer, use of a rosary or prayer beads, reading of scripture) Therapeutic touch BOX 10-6 Side and Adverse Effects of NSAIDs and Acetylsalicylic Acid NSAIDs ▪ Gastric irritation ▪ Hypotension ▪ Sodium and water retention ▪ Blood dyscrasias ▪ Dizziness ▪ Tinnitus ▪ Pruritus Acetylsalicylic Acid ▪ Gastric irritation ▪ Flushing ▪ Tinnitus ▪ Drowsiness ▪ Headaches ▪ Vision changes 113 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 132. The major concern with acetaminophen is hepatotoxicity. B. Opioid analgesics 1. Description a. These medications suppress pain impulses but can also suppress respiration and cough- ing by acting on the respiratory and cough center, located in the medulla of the brainstem. b. Review the client’s history and note that cli- ents with impaired renal or liver function may only be able to tolerate low doses of opioid analgesics. c. Intravenous route administration produces a faster effect than other routes but the effect lasts shorter to relieve pain d. Opioids, which produce euphoria and seda- tion, can cause physical dependence. e. Administer the medication 30 to 60 minutes before painful activities. f. Monitor the respiratory rate; if it is slower than 12 breaths/min in an adult, withhold the medication and notify the HCP. g. Monitor the pulse; if bradycardia develops, withhold the medication and notify the HCP. h Monitor the BP for hypotension and assess before administering pain medications to decrease the risk of adverse effects. i. Auscultate the lungs for normal breath sounds. j. Encourage activities such as turning, deep breathing, and incentive spirometry to help prevent atelectasis and pneumonia. k. Monitor the client’s level of consciousness. l. Initiate safety precautions. m. Monitor intake and output and assess the cli- ent for urine retention. n. Instruct the client to take oral doses with milk or a snack to reduce gastric irritation. o. Instruct the client to avoid activities that require alertness. p. Assess the effectiveness of the medication 30 minutes after adminstration. q. Have an opioid antagonist (e.g., naloxone), oxygen, and resuscitation equipment avail- able. An electronic infusion device is always used for con- tinuous or dose-demand IV infusion of opioid analgesics. 2. Codeine sulfate a. This medication is also used in low doses as a cough suppressant. b. It may cause constipation. c. Common medications in this class are hydro- codone and oxycodone (synthetic forms). 3. Hydromorphone a. The primary concern is respiration depres- sion. b. Other effects include drowsiness, dizziness, and orthostatic hypotension. c. Monitor vital signs, especially the respiratory rate and BP. 4. Morphine sulfate a. Morphine sulfate is used to ease acute pain resulting from myocardial infarction or can- cer, for dyspnea resulting from pulmonary edema, and as a preoperative medication. b. The major concern is respiratory depression, but postural hypotension, urine retention, constipation, and pupillary constriction may also occur; monitor the client for adverse effects. c. Morphine may cause nausea and vomiting by increasing vestibular sensitivity. d. It is contraindicated in severe respiratory dis- orders, head injuries, severe renal disease, or seizure activity, and in the presence of increased intracranial pressure. e. Monitor the client for urine retention. f. Monitor bowel sounds for decreased peristal- sis; constipation may occur. g. Monitor the pupil for changes; pinpoint pupils may indicate overdose. IX. Laboratory Reference Intervals For reference throughout the chapter, see Figure 10-2. A. Methods for drawing blood (Table 10-1) B. Serum sodium 1. A major cation of extracellular fluid. 2. Maintains osmotic pressure and acid-base bal- ance, and assists in the transmission of nerve impulses. 3. Is absorbed from the small intestine and excreted in the urine in amounts dependent on dietary intake. 4. Normal reference interval: 135 to 145 mEq/L (135 to 145 mmol/L). Drawing blood specimens from an extremity in which an IVsolution is infusing can produce an inaccu- rate result, depending on the test being performed and the type of solution infusing. Prolonged use of a tourni- quet before venous sampling can increase the blood level of potassium, producing an inaccurate result. C. Serum potassium 1. Amajor intracellular cation, potassium regulates cellular water balance, electrical conduction in muscle cells, and acid-base balance. 2. The body obtains potassium through dietary ingestion and the kidneys preserve or excrete potassium, depending on cellular need. F u n d a m e n t a l s 114 UNIT III Nursing Sciences
- 133. F u n d a m e n t a l s TOTAL BODYWEIGHT WHOLE BLOOD (percentage by volume) PLASMA (percentage by weight) Blood 8% Other fluids and tissues 92% Centrifuged sample of blood Buffy coat PLASMA 55% Albumins Globulins Fibrinogen Prothrombin 54% 38% 4% 1% PROTEINS Gases Ions Nutrients Regulatory substances Waste products OTHER SOLUTES LEUKOCYTES FORMED ELEMENTS 45% Platelets Proteins Water Other solutes 7% 91% 2% Neutrophils 60-70% Lymphocytes 20-25% Monocytes 3-8% Eosinophils 2-4% Basophils 0.5-1% 150,000-400,000 mm3 (150-400 × 109 /L) White blood cells 5000-10,000 mm3 (5.0-10.0 × 109 /L) FORMED ELEMENTS FIGURE 10-2 Approximate values for the components of blood in a normal adult. TABLE 10-1 Obtaining a Blood Sample Venipuncture Peripheral Intravenous Line Central Intravenous Line Check health care provider’s (HCP’s) prescription. Check HCP’s prescription. Check HCP’s prescription. Identify foods, medications, or other factors that may affect the procedure or results. Identifyfoods, medications, or other factors such as the type of solution infusing that may affect the procedure or results. Identify foods, medications, or other factors such as the type of solution infusing that may affect the procedure or results. Gather needed supplies, including gloves, needle (appropriate gauge and size), transfer/collection device per agency policy, specimen containers per agency policy, tourniquet, antiseptic swabs, 2Â 2 inch gauze, tape, tube label(s), biohazard bag, requisition form or bar code per agency policy. Gather needed supplies, including gloves, tourniquet, transparent dressing or other type of dressing, tape, 2Â 2 inch gauze, antiseptic agent, extension set (optional), two 5- or 10-mL normal saline flushes, one empty 5- or 10-mL syringe (depending on the amount of blood needed), transfer/collection device per agency policy, specimen containers per agency policy, alcohol- impregnated intravenous (IV) line end caps, tube labels, biohazard bag, requisition form or bar code per agency policy. Gather needed supplies, including gloves, transfer/collection device per agency policy, specimen containers per agency policy, two 5- or 10-mL normal saline flushes, one empty 5- or 10-mLsyringe (depending on the amount of blood needed), antiseptic swabs, alcohol- impregnated IV line end caps, 2 masks, biohazard bag, requisition form or bar code per agency policy. Perform hand hygiene. Identify the client with at least 2 accepted identifiers. Perform hand hygiene. Identify the client with at least 2 accepted identifiers. Perform hand hygiene. Identify the client with at least 2 accepted identifiers. Explain the purpose of the test and procedure to the client. Explain the purpose of the test and procedure to the client. Explain the purpose of the test and procedure to the client. Apply clean gloves. Place the client in a lying position or a semi-Fowler’s position. Place a small pillow or towel under the extremity. Prepare extension set if being used by priming with normal saline. Attach syringe to extension set. Place extension set within reach while maintaining aseptic technique and keeping it in the package. Place mask on self and client or ask client to turn the head away. Stop anyrunning infusions for at least 1 minute. Apply tourniquet 5 to 10 cm above the venipuncture site so it can be removed in 1 motion. Applytourniquet 10 to 15 cm above intravenous site. Clamp all ports. Scrub port to be used with antiseptic swab. Ask the client to open and close the fist several times, then clench the fist. Apply gloves. Scrub tubing insertion port with antiseptic solution or per agency policy. Attach 5- or 10-mL normal saline flush and unclamp line. Flush line with appropriate amount per agency policy and withdraw 5- 10 mL of blood to discard (per agency policy). Clamp line and detach flush. Continued 115 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 134. 3. Potassium levels are used to evaluate cardiac function, renal function, gastrointestinal func- tion, and the need for IV replacement therapy. 4. If the client is receiving a potassium supplemen- tation, this needs to be noted on the laboratory form. 5. Clients with elevated white blood cell (WBC) counts and platelet counts may have falsely ele- vated potassium levels. 6. Normal reference interval: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) D. Activated partial thromboplastin time (aPTT) 1. The aPTT evaluates how well the coagulation sequence (intrinsic clotting system) is function- ing by measuring the amount of time it takes in seconds for recalcified citrated plasma to clot after partial thromboplastin is added to it. 2. The test screens for deficiencies and inhibitors of all factors, except factors VII and XIII. 3. Usually, the aPTT is used to monitor the effec- tiveness of heparin therapy and screen for coag- ulation disorders. 4. Normal reference interval: 28 to 35 seconds (conventional and SI units), depending on the type of activator used. 5. If the client is receiving intermittent heparin ther- apy, draw the blood sample 1 hour before the next scheduled dose. 6. Do not draw samples from an arm into which heparin is infusing. 7. Transport specimen to the laboratory imme- diately. 8. Provide direct pressure to the venipuncture site for 3 to 5 minutes. 9. The aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. If the aPTTvalue is prolonged (longer than 87.5 sec- onds or per agencypolicy) in a client receiving IVheparin therapy or in any client at risk for thrombocytopenia, initiate bleeding precautions. E. Prothrombin time (PT) and international normal- ized ratio (INR) 1. Prothrombin is a vitamin K–dependent glyco- protein produced by the liver that is necessary for fibrin clot formation. 2. Each laboratory establishes a normal or control value based on the method used to perform the PT test. 3. The PT measures the amount of time it takes in seconds for clot formation and is used to monitor response to warfarin sodium therapy or to screen for dysfunction of the extrinsic clotting system resulting from liver disease, vitamin K deficiency, or disseminated intravascular coagulation. F u n d a m e n t a l s TABLE 10-1 Obtaining a Blood Sample—cont’d Venipuncture Peripheral Intravenous Line Central Intravenous Line Inspect to determine the vein to be used for venipuncture. Select the vein based on size and quality. Use the most distal site in the nondominant arm if possible. Palpate the vein with the index finger for resilience. Attach 5- or 10-mLnormal saline flush and unclamp line. Flush line with appropriate amount per agency policyand withdraw5-10 mLofblood to discard (per agencypolicy). Clamp line and detach flush syringe. Scrub port with antiseptic swab. Attach 5- or 10-mL syringe or transfer/collection device to port (depending on available equipment), unclamp line, and withdraw needed sample or attach specimen container to withdraw using vacuum system. Clamp line and detach syringe or transfer/collection device. Clean site with antiseptic swabs or per agency policy, using a circular scrubbing motion, inward to outward for 30 seconds. Insert the needle bevel up at a 15- to 30- degree angle. Collect blood in collection device per agency policy. Scrub tubing insertion port. Attach 5- or 10-mL syringe, extension set, or transfer/collection device to port (depending on available equipment), unclamp line, and withdraw needed sample or attach specimen container to withdraw using vacuum system. Clamp line and detach syringe or transfer/collection device. Scrub port with antiseptic swab. Attach a 5- or 10-mL normal saline flush. Unclamp line and flush with amount per agency policy. Clamp line, remove flush, and place end cap on IV line. Remove masks. Release tourniquet. Apply 2Â 2 inch gauze over insertion site. Remove needle and engage safety on needle. Apply pressure for 2 minutes. If the client is on anticoagulants, apply pressure for several minutes. Perform hand hygiene. Remove tourniquet and flush with normal saline to ensure patency. Transfer specimen to collection device per agency policy if not previously collected. Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy. Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy. Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy. 116 UNIT III Nursing Sciences
- 135. 4. A PT value within 2 seconds (plus or minus) of the control is considered normal. 5. The INR is a frequently used test to measure the effects of some anticoagulants. 6. The INR standardizes the PT ratio and is calcu- lated in the laboratory setting by raising the observed PT ratio to the power of the interna- tional sensitivity index specific to the thrombo- plastin reagent used. 7. If a PT is prescribed, baseline specimen should be drawn before anticoagulation therapy is started; note the time of collection on the labora- tory form. 8. Provide direct pressure to the venipuncture site for 3 to 5 minutes. 9. Concurrent warfarin therapy with heparin ther- apy can lengthen the PT for up to 5 hours after dosing. 10. Diets high in green leafy vegetables can increase the absorption of vitamin K, which shortens the PT. 11. Orally administered anticoagulation therapy usually maintains the PTat 1.5 to 2 times the lab- oratory control value. 12. Normal reference intervals a. PT: 11 to 12.5 seconds (conventional and SI units) b. INR: 2 to 3 for standard warfarin therapy c. INR: 3 to 4.5 for high-dose warfarin therapy Ifthe PTvalue is longerthan 32seconds and the INRis greaterthan 3.0 in a client receiving standard warfarin ther- apy (or per agencypolicy), initiate bleeding precautions. F. Platelet count 1. Platelets function in hemostatic plug formation, clot retraction, and coagulation factor activation. 2 Platelets are produced by the bone marrow to function in hemostasis. 3. Normal reference interval:150,000-400,000 mm3 (150–400 Â 109 /L) 4. Monitor the venipuncture site for bleeding in cli- ents with known thrombocytopenia. 5. High altitudes, chronic cold weather, and exer- cise increase platelet counts. 6. Bleeding precautions should be instituted in cli- ents when the platelet count falls sufficiently below the normal level; the specific value for implementing bleeding precautions usually is determined by agency policy. Monitor the platelet count closely in clients receiv- ing chemotherapy because of the risk for thrombocyto- penia. In addition, any client who will be having an invasive procedure (such as a liver biopsy or thoracen- tesis) should have coagulation studies and platelet counts done before the procedure. G. Hemoglobin and hematocrit 1. Hemoglobin is the main component of erythro- cytes and serves as the vehicle for transporting oxygen and carbon dioxide. 2. Hematocrit represents red blood cell (RBC) mass and is an important measurement in the pres- ence of anemia or polycythemia (Table 10-2). 3. Fasting is not required for this test. H. Lipids 1. Blood lipids consist primarily of cholesterol, tri- glycerides, and phospholipids. 2. Lipid assessment includes total cholesterol, high- density lipoprotein (HDL), low-density lipopro- tein (LDL), and triglycerides. 3. Cholesterol is present in all body tissues and is a major component of LDLs, brain and nerve cells, cell membranes, and some gallbladder stones. 4. Triglycerides constitute a major part of very low- density lipoproteins and a small part of LDLs. 5. Triglycerides are synthesized in the liver from fatty acids, protein, and glucose, and are obtained from the diet. 6. Increased cholesterol levels, LDL levels, and tri- glyceride levels place the client at risk for coro- nary artery disease. 7. HDLhelps to protect against the risk of coronary artery disease. 8. Oral contraceptives may increase the lipid level. 9. Instruct the client to abstain from food and fluid, except for water, for 12 to 14 hours and from alcohol for 24 hours before the test. 10. Instruct the client to avoid consuming high- cholesterol foods with the evening meal before the test. 11. Normal reference intervals (Table 10-3). I. Fasting blood glucose 1. Glucose is a monosaccharide found in fruits and is formed from the digestion of carbohydrates and the conversion of glycogen by the liver. 2. Glucose is the main source of cellular energy for the body and is essential for brain and erythro- cyte function. F u n d a m e n t a l s TABLE 10-2 Hemoglobin and Hematocrit: Reference Intervals Blood Component Reference Interval Hemoglobin (altitude dependent) Male adult 14-18 g/dL (140-180 mmol/L) Female adult 12-16 g/dL (120-160 mmol/L) Hematocrit (altitude dependent) Male adult 42%-52% (0.42-0.52) Female adult 37%-47% (0.37-0.47) 117 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 136. F u n d a m e n t a l s 3. Fasting blood glucose levels are used to help diagnose diabetes mellitus and hypoglycemia. 4. Instruct the client to fast for 8 to 12 hours before the test. 5. Instruct a client with diabetes mellitus to with- hold morning insulin or oral hypoglycemic med- ication until after the blood is drawn. 6. Normal reference interval: glucose (fasting) 70-110 mg/dL (4-6 mmol/L) J. Glycosylated hemoglobin (HgbA1C) 1. HgbA1C is blood glucose bound to hemoglobin. 2. Hemoglobin A1c (glycosylated hemoglobin A; HbA1c) is a reflection of how well blood glucose levels have been controlled for the past 3 to 4 months. 3. Hyperglycemia in clients with diabetes is usually a cause of an increase in the HbA1c. 4. Fasting is not required before the test. 5. Normal reference intervals: 4.0%–6.0% (4.0%– 6.0%) 6. HgbA1C and estimated average glucose (eAG) reference intervals (Table 10-4). K. Renal function studies 1. Serum creatinine a. Creatinine is a specific indicator of renal function. b. Increased levels of creatinine indicate a slow- ing of the glomerular filtration rate. c. Instruct the client to avoid excessive exercise for 8 hours and excessive red meat intake for 24 hours before the test. d. Normal reference interval: 0.6–1.3 mg/dL (53–115 µmol/L) 2. Blood urea nitrogen (BUN) a. Urea nitrogen is the nitrogen portion of urea, a substance formed in the liver through an enzymatic protein breakdown process. b. Urea is normally freely filtered through the renal glomeruli, with a small amount reab- sorbed in the tubules and the remainder excreted in the urine. c. Elevated levels indicate a slowing of the glo- merular filtration rate. d. BUN and creatinine ratios should be analyzed when renal function is evaluated. e. Normal reference interval: 6–20 mg/dL (2.1– 7.1 mmol/L) L. White blood cell (WBC) count 1. WBCs function in the immune defense system of the body. 2. The WBC differential provides specific informa- tion on WBC types. 3. A “shift to the left” (in the differential) means that an increased number of immature neutro- phils is present in the blood. 4. Alow total WBC count with a left shift indicates a recoveryfrom bonemarrow depression or an infec- tion of such intensity that the demand for neutro- phils in the tissue is higher than the capacity of the bone marrow to release them into the circulation. 5. Ahigh total WBC count with a left shift indicates an increased release of neutrophils by the bone marrow in response to an overwhelming infec- tion or inflammation. 6. An increased neutrophil count with a left shift is usually associated with bacterial infection. 7. A “shift to the right” means that cells have more than the usual number of nuclear segments; found in liver disease, Down syndrome, and megaloblastic and pernicious anemia. 8. Normal reference interval: 5000–10,000 mm3 (5.0–10.0 Â 109 /L) Monitor the WBC count and differential closelyin cli- ents receiving chemotherapy because of the risk for neu- tropenia; neutropenia places the client at riskfor infection. TABLE 10-3 Lipids: Reference Intervals Blood Component Reference Interval Cholesterol < 200 mg/dL (< 5.2 mmol/L) High-density lipoproteins (HDLs) Male: > 40 mg/dL (> 1.04 mmol/L) Female: > 50 mg/dL (> 1.3 mmol/L) Low-density lipoproteins (LDLs) Recommended: < 100 mg/dL (< 2.6 mmol/L) Near optimal: 100-129 mg/dL (2.6-3.34 mmol/L) Moderate risk for coronary artery disease (CAD): 130-159 mg/dL (3.37-4.12 mmol/L) High risk for CAD: > 160 mg/dL (> 4.14 mmol/L) Triglycerides < 150 mg/dL (< 1.7 mmol/L) TABLE 10-4 Glycosylated Hemoglobin (HgbA1C) and Estimated Average Glucose (eAG) HgbA1C % eAG mg/dL eAG mmol/L 6 126 7.0 6.5 140 7.8 7 154 8.6 7.5 169 9.4 8 183 10.1 8.5 197 10.9 9 212 11.8 9.5 226 12.6 10 240 13.4 American Diabetes Association, DiabetesPro: Estimated average glucose, eAG/A1C Conversion Calculator (website): http://professional.diabetes.org/diapro/glucose_calc. 118 UNIT III Nursing Sciences
- 137. CRITICALTHINK ING W hat Should Y ou Do? Answer: The client’s vital signs are showing a significant change, particularly the blood pressure, heart rate, and oxy- gen saturation levels. The nurse should first compare the vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about howmuch ofa change has occurred in these parameters. The nurse should quickly consider the following when determin- ing the next action: (1) Is the equipment working properly? (2) Is the correct equipment being used? (3) Is there a con- dition or procedure in the client’s history that can be attrib- uted to this change? (4) Are there environmental factors that could influence the change in the client’s vitalsigns? (5) Does this change necessitate contacting the surgeon? Given the significant change from the baseline vital signs, and after checking equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding, ie, drainage on the dressing, bloodyoutput in a surgical drain, swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status. References: Lewis et al. (2014), pp. 350, 354; Potter et al. (2015), p. 272. P RACTI CE Q U ES TI O N S 63. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a pro- thrombin time (PT) of 35 (35) seconds and an inter- national normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin 64. A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. “I will be sure to ask my client what his pain level is on a scale of 0 to 10.” 2. “I know that I should follow up after giving med- ication to make sure it is effective.” 3. “I know that pain in the older client might man- ifest as sleep disturbances or depression.” 4. “I will be sure to cue in to any indicators that the client may be exaggerating their pain.” 65. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 3 mg/dL (1.05 mmol/L) 2. 15 mg/dL (5.25 mmol/L) 3. 29 mg/dL (10.15 mmol/L) 4. 35 mg/dL (12.25 mmol/L) 66. The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indi- cates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic 67. A client is receiving a continuous intravenous infu- sion of heparin sodium to treat deep vein thrombo- sis. The client’s activated partial thromboplastin time (aPTT) is 65 seconds (65 seconds). The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is 68. A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potas- sium level, if noted in the client’s laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L) 69. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35 Â 109 /L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 µmol/L) 6. White blood cells, 3000 mm3 (3.0 Â 109 /L) F u n d a m e n t a l s 119 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 138. F u n d a m e n t a l s 70. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client’s medication history, and determines it is nec- essary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide 71. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia 72. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client’s white blood cell count was which value? 1. 2000 mm3 (2.0 Â 109 /L) 2. 5800 mm3 (5.8 Â 109 /L) 3. 8400 mm3 (8.4 Â 109 /L) 4. 11,500 mm3 (11.5 Â 109 /L) 73. Aclient brought to the emergency department states that he has accidentally been taking 2 times his pre- scribed dose of warfarin for the past week. After not- ing that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thrombo- plastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 74. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the following vital signs: temperature 97.2 °F (36.2 °C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the health care provider (HCP) immediately. 4. Check the medication administration history on the PCA pump. 75. An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client’s history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease 76. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 Â 109 /L). The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client’s medical record. AN S WERS 63. 2 Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibril- lation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect. Test-Taking Strategy: Focus on the subject, a PTof 35 seconds and an INR of 3.5. Recall the normal ranges for these values and remember that a PT greater than 32 seconds and an INR greater than 3 for standard warfarin therapy places the client at risk for bleeding; this will direct you to the correct option. Review: The normal prothrombin time and INR levels Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Clotting References: Lewis et al. (2014), p. 627; Rosenjack Burchum, Rosenthal (2016), pp. 622–623. 64. 4 Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is 120 UNIT III Nursing Sciences
- 139. exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement as the answer. Recall that pain is a highly individual experience, and the nurse should not assume that the client is exaggerating pain. Review: Management of pain Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Pain Priority Concepts: Clinical Judgment; Pain Reference: Lewis et al. (2014), pp. 122, 134. 65. 2 Rationale: The normal BUN level is 6 to 20 mg/dL (2.1 to 7.1 mmol/L). Values of 29 mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. Test-Taking Strategy: Focus on the subject, adequate fluid replacement and the normal BUN level. The correct option is the only option that identifies a normal value. Review: The normal blood urea nitrogen level Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Fluid and Electrolyte Balance References: Lewis et al. (2014), p. 1057; Pagana, Pagana (2014), pp. 511–514. 66. 2 Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Takinga rectal temperaturefor a client who hasunder- gone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature isacceptable. Takingan axillarytemperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to mea- sure the temperature on the neck behind the ear, avoiding the forehead. Test-Taking Strategy: Note the strategic words, need for fur- ther teaching. These words indicate a negative event query and the need to select the incorrect action as the answer. Recall that nasal congestion is a reason to avoid taking an oral tem- perature, as the nasal congestion will cause problems with breathing while the temperature is being taken. Review: Temperature measurement methods Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Vital Signs Priority Concepts: Teaching and Learning; Thermoregulation Reference: Perry, Potter, Ostendorf (2014), pp. 68–69, 76. 67. 4 Rationale: The normal aPTTvaries between 28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42 to 52.5) and 2.5 (70 to 87.5) times normal. This means that the client’s value should not be less than 42 seconds or greater than 87.5 seconds. Thus the client’s aPTT is within the therapeutic range and the dose should remain unchanged. Test-Taking Strategy: Focus on the subject, the expected aPTT for a client receiving a heparin sodium infusion. Remember that the normal range is 28 to 35 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 28 and 35 will yield a range of 42 to 87.5 seconds). This client’s value is 65 seconds Review: The aPTT level and the expected level if the client is receiving heparin Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Clotting Reference: Lewis et al. (2014), p. 627. 68. 1 Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Adminis- tering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dys- rhythmias. The remaining options are within the normal range. Test-Taking Strategy: Note the subject of the question, the level that should be reported. This indicates that you are looking for an abnormal level. Remember, the normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). This will direct you to the correct option. Review: The normal serum potassium level Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Fluid and Electrolyte Balance F u n d a m e n t a l s 121 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 140. References: Lewis et al. (2014), p. 296; Pagana, Pagana (2014), p. 409. 69. 1, 2, 4, 6 Rationale: The normal values include the following: platelets 150,000–400,000 mm3 (150–400 Â 109 /L); sodium 135– 145 mEq/L (135–145 mmol/L); potassium 3.5–5.0 mEq/L (3.5–5.0 mmol/L); segmented neutrophils 60%–70% (0.60– 0.70); serum creatinine 0.6–1.3 mg/dL (53–115 µmol/L); and white blood cells 5000–10,000 mm3 (5.0–10.0 Â 109 /L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low. Test-Taking Strategy: Focus on the subject, the abnormal lab- oratory values that need to be reported. Recalling the normal laboratory values for the blood studies identified in the options will assist in answering this question. Review: The normal laboratory values Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Collaboration Reference: Lewis et al. (2014), pp. 626, 661, 1702–1703 70. 1, 2, 3 Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these med- ications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a cal- cium channel blocker such as amlodipine; therefore, this com- bination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide. Test-Taking Strategy: Note the subject of the question, data provided by the client necessitating contacting the HCP. Deter- mining that ibuprofen is classified as an NSAID will help you to determine that it should not be combined with anticoagu- lants. Also recalling that hypoglycemia can occur as an adverse effect will help you to recall that these medications should not be combined. From the remaining options, it is necessary to remember that toxicity can result if NSAIDs are combined with calcium channel blockers. Review: Medication interactions for NSAIDs, specifically ibuprofen Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Pain Priority Concepts: Clinical Judgment; Safety Reference: Rosenjack Burchum, Rosenthal (2016), pp. 861, 866–868. 71. 4 Rationale: The normal reference range for the glycosylated hemoglobin A1c is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is use- ful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glu- cose for a glycosylated hemoglobin A1c of 9% is 212 mg/dL (11.8 mmol/L). Elevations indicate continued need for teach- ing related to the prevention of hyperglycemic episodes. Test-Taking Strategy: Focus on the subject, a glycosylated hemoglobin A1c level of 9%. Recalling the normal value and that an elevated value indicates hyperglycemia will assist in directing you to the correct option. Review: Glycosylated hemoglobin A1c Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Client Education; Glucose Regulation References: Lewis et al. (2014), pp. 1150, 1175; Pagana, Pagana (2014), p. 266. 72. 1 Rationale: The normal WBC count ranges from 5000– 10,000 mm3 (5–10 Â 109 /L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the cli- ent’s values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are nor- mal values. Test-Taking Strategy: Focus on the subject, the need to imple- ment neutropenic precautions. Recalling that the normal WBC count is 5000–10,000 mm3 (5–10 Â 109 /L) will direct you to the correct option. Review: The normal adult white blood cell differential count Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Infection References: Lewis et al. (2014), pp. 625–626. 73. 4 Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client’s anti- coagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy. Test-Taking Strategy: Focus on the subject, a client who has taken an excessive dose of warfarin. Eliminate the option with aPTTfirst because it is unrelated to warfarin therapy and relates to heparin therapy. Next, eliminate the options indicating to administer an antidote and to transfuse the client because these therapies would not be implemented unless the PT and INR levels were known. Review: Care to the client receiving warfarin therapy Level of Cognitive Ability: Applying F u n d a m e n t a l s 122 UNIT III Nursing Sciences
- 141. Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Clotting Reference: Lewis et al. (2014), p. 627. 74. 2 Rationale: The primary concern with opioid analgesics is respi- ratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the cli- ent is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnor- mality still exists after arousing the client. Test-Taking Strategy: First, note the strategic word, next. Focus on the data in the question and determine if an abnormality exists. It is clear that an abnormality exists because the client is drowsy and the vital signs are outside of the normal range. Recall that attempting to arouse the client should come before further assessment of the pump. The client should always be assessed before the equipment, before con- tacting the HCP, and before documentation. Review: Management of potential opioid overdose. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Pain Priority Concepts: Clinical Judgment; Pain Reference: Lewis et al. (2014), p. 164. 75. 3 Rationale: The normal hemoglobin level for an adult female client is 12–16 g/dL (120–160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity. Test-Taking Strategy: Note the strategic words, most likely. Evaluate each of the conditions in the options in terms of their pathophysiology and whether each is likely to raise or lower the hemoglobin level. Also, note the relationship between hemoglobin level in the question and the correct option. Review: The normal hemoglobin level Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Gas Exchange Reference: Lewis et al. (2014), pp. 628, 638. 76. 4 Rationale: A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 Â 109 /L). The nurse should place the report containing the normal laboratory value in the client’s medical record. A platelet count of 300,000 mm3 (300 Â 109 /L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. Test-Taking Strategy: Focus on the subject, a platelet count of 300,000 mm3 (300 Â 109 /L). Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options indicating to report the abnormally low count and placing the client on bleeding precautions first. From the remaining options, recalling the normal range for this laboratory test will direct you to the correct option. Review: The normal platelet count Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Laboratory Values Priority Concepts: Clinical Judgment; Clotting Reference: Lewis et al. (2014), p. 626. F u n d a m e n t a l s 123 CHAPTER 10 Vital Signs and Laboratory Reference Intervals
- 142. F u n d a m e n t a l s CH AP TER 11 Nutrition PRIORITYCONCEPT Health Promotion; Nutrition CRITICALTHINK ING W hat Should Y ou Do? A client has been placed on a fluid restriction due to acute kidney injury. The client complains of thirst and asks what can be done to relieve this discomfort. What measures should the nurse tell the client to take to relieve thirst while adhering to the fluid restriction? Answer located on p. 130. I. Nutrients A. Carbohydrates 1. Carbohydrates are the preferred source of energy. 2. Sugars, starches, and cellulose provide 4 cal/g. 3. Carbohydrates promote normal fat metabolism, spare protein, and enhance lower gastrointesti- nal function. 4. Major food sources of carbohydrates include milk, grains, fruits, and vegetables. 5. Inadequate carbohydrate intake affects metabolism. B. Fats 1. Fats provide a concentrated source and a stored form of energy. 2. Fats protect internal organs and maintain body temperature. 3. Fats enhance absorption of the fat-soluble vitamins. 4. Fats provide 9 cal/g. 5. Inadequate intake of essential fatty acids leads to clinical manifestations of sensitivity to cold, skin lesions, increased risk of infection, and amenor- rhea in women. 6. Diets high in fat can lead to obesity and increase the risk of cardiovascular disease and some cancers. C. Proteins 1. Amino acids, which make up proteins, are critical to all aspects of growth and development of body tissues, and provide 4 cal/g. 2. Proteins build and repair body tissues, regulate fluid balance, maintain acid-base balance, pro- duce antibodies, provide energy, and produce enzymes and hormones. 3. Essential amino acids are required in the diet because the body cannot manufacture them. 4. Complete proteins contain all essential amino acids; incomplete proteins lack some of the essential fatty acids. 5. Inadequate protein can cause protein energy malnutrition and severe wasting of fat and muscle tissue. Major stages of the lifespan with specific nutritional needs are pregnancy, lactation, infancy, childhood, and adolescence. Adults and older adults may experience physiological aging changes, which influence individual nutritional needs. D. Vitamins (Box 11-1) 1. Vitamins facilitate metabolism of proteins, fats, and carbohydrates and act as catalysts for meta- bolic functions. 2. Vitamins promote life and growth processes, and maintain and regulate body functions. 3. Fat-soluble vitamins A, D, E, and Kcan be stored in the body, so an excess can cause toxicity. 4. The B vitamins and vitamin C are water-soluble vitamins, are not stored in the body, and can be excreted in the urine. E. Minerals (Box 11-2) 1. Minerals are components of hormones, cells, tis- sues, and bones. 2. Minerals act as catalysts for chemical reactions and enhancers of cell function. 3. Almost all foods contain some form of minerals. 4. A deficiency of minerals can develop in chroni- cally ill or hospitalized clients. 5. Electrolytes play a major role in osmolality and body water regulation, acid-base balance, enzyme reactions, and neuromuscular activity (see Chapter 8 for additional information regarding electrolytes). 124
- 143. Always assess the client’s ability to eat and swallow and promote independence in eating as much as is possible. II. MyPlate (Fig. 11-1) A. Providesa description ofa balanced diet that includes grains, vegetables, fruits, dairy products, and protein foods (see http://www.choosemyplate.gov/) B. Anutritionist should be consulted for individualized dietary recommendations. C. Guidelines 1. Avoid eating oversized portions of foods. 2. Fill half of the plate with fruits and vegetables. 3. Vary the type of vegetables and fruits eaten. 4. Select at least half of the grains as whole grains. 5. Ensure that foods from the dairy group are high in calcium. 6. Drink milk that is fat-free or low fat (1%). F u n d a m e n t a l s BOX 11-1 Food Sources of Vitamins Water-Soluble Vitamins Folic acid: Green leafyvegetables; liver, beef, and fish; legumes; grapefruit and oranges Niacin: Meats, poultry, fish, beans, peanuts, grains Vitamin B1 (thiamine): Pork and nuts, whole-grain cereals, and legumes Vitamin B2 (riboflavin): Milk, lean meats, fish, grains Vitamin B6 (pyridoxine): Yeast, corn, meat, poultry, fish Vitamin B12 (cobalamin): Meat, liver Vitamin C (ascorbic acid): Citrus fruits, tomatoes, broccoli, cabbage Fat-Soluble Vitamins Vitamin A: Liver, egg yolk, whole milk, green or orange vegeta- bles, fruits Vitamin D: Fortified milk, fish oils, cereals Vitamin E: Vegetable oils; green leafy vegetables; cereals; apri- cots, apples, and peaches Vitamin K: Green leafy vegetables; cauliflower and cabbage BOX 11-2 Food Sources of Minerals Calcium Cheese Collard greens Milk and soy milk Rhubarb Sardines Tofu Yogurt Chloride Salt Iron Breads and cereals Dark green vegetables Dried fruits Egg yolk Legumes Liver Meats Magnesium Avocado Canned white tuna Cauliflower Cooked rolled oats Green leafy vegetables Milk Peanut butter Peas Pork, beef, chicken Potatoes Raisins Yogurt Phosphorus Fish Nuts Organ meats Pork, beef, chicken Whole-grain breads and cereals Potassium Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Pork, beef, veal Potatoes Raisins Spinach Strawberries Tomatoes Sodium Bacon Butter Canned food Cheese Cured pork Hot dogs Ketchup Lunch meat Milk Mustard Processed food Snack food Soy sauce Table salt White and whole-wheat bread Zinc Eggs Leafy vegetables Meats Protein-rich foods FIGURE 11-1 MyPlate. (From U.S. Department of Agriculture. Available at http://www.choosemyplate.gov.) 125 CHAPTER 11 Nutrition
- 144. F u n d a m e n t a l s 7. Eat protein foods that are lean. 8. Select fresh foods over frozen or canned foods. 9. Drink water rather than liquids that contain sugar. Always consider the client’s cultural and personal choices when planning nutritional intake. III. Therapeutic Diets A. Clear liquid diet 1. Indications a. Clear liquid diet provides fluids and some electrolytes to prevent dehydration. b. Clear liquid diet is used as an initial feeding after complete bowel rest. c. Clear liquid diet is used initially to feed a mal- nourished person or a person who has not had any oral intake for some time. d. Clear liquid diet is used for bowel preparation for surgery or diagnostic tests, as well as post- operatively and in clients with fever, vomit- ing, or diarrhea. e. Clear liquid diet is used in gastroenteritis. 2. Nursing considerations a. Clear liquid diet is deficient in energy (calo- ries) and many nutrients. b. Clear liquid diet is easily digested and absorbed. c. Minimal residue is left in the gastrointestinal tract. d. Clients may find a clear liquid diet unappetiz- ing and boring. e. As a transition diet, clear liquids are intended for short-term use. f. Clear liquids and foods that are relatively transparent to light and are liquid at body temperature are considered “clear liquids,” such as water, bouillon, clear broth, carbon- ated beverages, gelatin, hard candy, lemon- ade, ice pops, and regular or decaffeinated coffee or tea. g. By limiting caffeine intake, an upset stomach and sleeplessness may be prevented. h. The client may consume salt and sugar. i. Dairy products and fruit juices with pulp are not clear liquids. Monitor the client’s hydration status by assessing intake and output, assessing weight, monitoring for edema, and monitoring for signs of dehydration. Each kilogram (2.2 lb) ofweight gained or lost is equalto 1liter of fluid retained or lost. B. Full liquid diet 1. Indication: May be used as a transition diet after clear liquids following surgery or for clients who have difficulty chewing, swallowing, or tolerat- ing solid foods 2. Nursing considerations a. A full liquid diet is nutritionally deficient in energy (calories) and many nutrients. b. The diet includes clear and opaque liquid foods, and those that are liquid at body temperature. c. Foods include all clear liquids and items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, fruit juices, and strained vegetable juices. d. Use of a complete nutritional liquid supple- ment is often necessary to meet nutrient needs for clients on a full liquid diet for more than 3 days. Provide nutritional supplements such as those high in protein, as prescribed, for the client on a liquid diet. C. Mechanical soft diet 1. Indications a. Provides foods that have been mechanically altered in texture to require minimal chewing b. Used for clients who have difficulty chewing but can tolerate more variety in texture than a liquid diet offers c. Used for clients who have dental problems, surgery of the head or neck, or dysphagia (requires swallowing evaluation and may require thickened liquids if the client has swallowing difficulties) 2. Nursing considerations a. Degree of texture modification depends on individual need, including pureed, mashed, ground, or chopped. b. Foods to be avoided in mechanically altered diets include nuts; dried fruits; raw fruits and vegetables; fried foods; tough, smoked, or salted meats; and foods with coarse textures. D. Soft diet 1. Indications a. Used for clients who have difficulty chewing or swallowing b. Used for clients who have ulcerations of the mouth or gums, oral surgery, broken jaw, plastic surgery of the head or neck, or dyspha- gia, or for the client who has had a stroke 2. Nursing considerations a. Clients with mouth sores should be served foods at cooler temperatures. b. Clients who have difficulty chewing and swal- lowing because of dry mouth can increase sal- ivary flow by sucking on sour candy. c. Encourage the client to eat a variety of foods. d. Provide plenty of fluids with meals to ease chewing and swallowing of foods. e. Drinking fluids through a straw may be easier than drinking from a cup or glass; a straw may 126 UNIT III Nursing Sciences
- 145. F u n d a m e n t a l s not be allowed for clients with dysphagia (because of the risk of aspiration). f. All foods and seasonings are permitted; however, liquid, chopped, or pureed foods or regular foods with a soft consistency are tolerated best. g. Foods that contain nuts or seeds, which easily can become trapped in the mouth and cause discomfort, should be avoided. h. Raw fruits and vegetables, fried foods, and whole grains should be avoided. Consider the client’s disease or illness and how it may affect nutritional status. E. Low-fiber (low-residue) diet 1. Indications a. Supplies foods that are least likely to form an obstruction when the intestinal tract is nar- rowed by inflammation or scarring or when gastrointestinal motility is slowed b. Used for inflammatory bowel disease, partial obstructions of the intestinal tract, gastroenter- itis,diarrhea,orothergastrointestinaldisorders 2. Nursing considerations a. Foods that are low in fiber include white bread, refined cooked cereals, cooked potatoes with- out skins, white rice, and refined pasta. b. Foods to limit or avoid are raw fruits (except bananas), vegetables, nuts and seeds, plant fiber, and whole grains. c. Dairy products should be limited to 2 serv- ings a day. F. High-fiber (high-residue) diet 1. Indication: Used for constipation, irritable bowel syndrome when the primary symptom is alter- nating constipation and diarrhea, and asymp- tomatic diverticular disease 2. Nursing considerations a. High-fiber diet provides 20 to 35 g of dietary fiber daily. b. Volume and weight are added to the stool, speeding the movement of undigested mate- rials through the intestine. c. High-fiber foods are fruits and vegetables and whole-grain products. d. Increase fiber gradually and provide adequate fluids to reduce possible undesirable side effects such as abdominal cramps, bloating, diarrhea, and dehydration. e. Gas-forming foods should be limited (Box 11-3). G. Cardiac diet (Box 11-4) 1. Indications a. Indicated for atherosclerosis, diabetesmellitus, hyperlipidemia, hypertension, myocardial infarction, nephrotic syndrome, and renal failure b. Reduces the risk of heart disease c. Dietary Approaches to Stop Hypertension (DASH) diet: recommended to prevent and control hypertension, hypercholesterolemia, and obesity d. The DASH diet includes fruits, vegetables, whole grains, and low-fat dairy foods; meat, fish, poultry, nuts, and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fats. 2. Nursing considerations a. Restrict total amounts of fat, including satu- rated, trans, polyunsaturated, and monoun- saturated; cholesterol; and sodium. b. Teach the client about the DASH diet or other prescribed diet. H. Fat-restricted diet 1. Indications a. Used to reduce symptoms of abdominal pain, steatorrhea, flatulence, and diarrhea associ- ated with high intakes of dietary fat, and to decrease nutrient losses caused by ingestion of dietary fat in individuals with malabsorp- tion disorders b. Used for clients with malabsorption disor- ders, pancreatitis, gallbladder disease, and gastroesophageal reflux 2. Nursing considerations a. Restrict total amount offat,includingsaturated, trans, polyunsaturated, and monounsaturated. b. Clients with malabsorption may also have difficulty tolerating fiber and lactose. BOX 11-3 Gas-Forming Foods Apples Artichokes Barley Beans Bran Broccoli Brussels sprouts Cabbage Celery Figs Melons Milk Molasses Nuts Onions Radishes Soybeans Wheat Yeast BOX 11-4 Sodium-Free Spices and Flavorings Allspice Almond extract Bay leaves Caraway seeds Cinnamon Curry powder Garlic powder or garlic Ginger Lemon extract Maple extract Marjoram Mustard powder Nutmeg 127 CHAPTER 11 Nutrition
- 146. F u n d a m e n t a l s c. Vitamin and mineral deficiencies may occur in clients with diarrhea or steatorrhea. d. A fecal fat test may be prescribed and indi- cates fat malabsorption with excretion of more than 6 to 8 g of fat (or more than 10% of fat consumed) per day during the 3 days of specimen collection. I. High-calorie, high-protein diet 1. Indication: Used for severe stress, burns, wound healing, cancer, human immunodeficiency virus, acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, respira- tory failure, or any other type of debilitating disease 2. Nursing considerations a. Encourage nutrient-dense, high-calorie, high- protein foods such as whole milk and milk products, peanut butter, nuts and seeds, beef, chicken, fish, pork, and eggs. b. Encourage snacks between meals, such as milkshakes, instant breakfasts, and nutri- tional supplements. Calorie counts assist in determining the client’s total nutritionalintake and can identifya deficit orexcess intake. J. Carbohydrate-consistent diet 1. Indication: Used for clients with diabetes melli- tus, hypoglycemia, hyperglycemia, and obesity 2. Nursing considerations a. The Exchange System for Meal Planning, developed by the Academy of Nutrition and Dietetics and the American Diabetes Association, is a food guide that may be recommended. b. The Exchange System groups foods according to the amounts of carbohydrates, fats, and proteins they contain; major food groups include the carbohydrate, meat and meat sub- stitute, and fat groups. c. Acarbohydrate consistent diet focuseson main- taining a consistent amount of carbohydrate intake each dayand with each meal;also known as “carb counting.” For additional information, refer to: http://www.livestrong.com/article/ 436101-the-consistent-carbohydrate-diet-for- diabetics/ d. The MyPlate diet may also be recommended. K. Sodium-restricted diet (see Box 11-4) 1. Indication: Used for hypertension, heart failure, renal disease, cardiac disease, and liver disease 2. Nursing considerations a. Individualized; can include 4 g of sodium daily (no-added-salt diet), 2 to 3 g of sodium daily (moderate restriction), 1 g of sodium daily (strict restriction), or 500 mg of sodium daily (severe restriction and sel- dom prescribed) b. Encourage intake of fresh foods, rather than processed foods, which contain higher amounts of sodium. c. Canned, frozen, instant, smoked, pickled, and boxed foods usually contain higher amounts of sodium. Lunch meats, soy sauce, salad dressings, fast foods, soups, and snacks such as potato chips and pret- zels also contain large amounts of sodium; teach patients to read nutritional facts on product packaging regarding sodium con- tent per serving. d. Certain medications contain significant amounts of sodium. e. Salt substitutes may be used to improve palat- ability; most salt substitutes contain large amounts of potassium and should not be used by clients with renal disease. L. Protein-restricted diet 1. Indication: Used for renal disease and end-stage liver disease 2. The nutritional status of critically ill clients with protein-losing renal diseases, malabsorption syndromes, and continuous renal replacement therapy or dialysis should have their protein needs assessed by estimating the protein equiva- lent of nitrogen appearance (PNA); a nutritionist should be consulted. 3. Nursing considerations a. Provide enough protein to maintain nutri- tional status but not an amount that will allow the buildup of waste products from protein metabolism (40 to 60 g of protein daily). b. The lessprotein allowed, the more important it becomes that all protein in the diet be of high biological value (contain all essential amino acids in recommended proportions). c. An adequate total energy intake from foods is critical for clients on protein-restricted diets (protein will be used for energy, rather than for protein synthesis). d. Special low-protein products, such as pastas, bread, cookies, wafers, and gelatin made with wheat starch, can improve energy intake and add variety to the diet. e. Carbohydrates in powdered or liquid forms can provide additional energy. f. Vegetables and fruits contain some protein and, for very low-protein diets, these foods must be calculated into the diet. g. Foods are limited from the milk, meat, bread, and starch groups. M. Gluten-free diet: A treatment for celiac disease and gluten sensitivity for clients needing the protein fraction “gluten” eliminated from their diet. See Chapter 37 for information on this diet. 128 UNIT III Nursing Sciences
- 147. F u n d a m e n t a l s Fluid restrictions may be prescribed for clients with hyponatremia, severe extracellular cellular volume excess, and renal disorders. Ask specifically about client preferences regarding types of oral fluids and tempera- ture preference of fluids. N. Renal diet (see Box 11-2) 1. Indication: Used for the client with acute kidney injury or chronic kidney disease and those requiring hemodialysis or peritoneal dialysis 2. Nursing considerations a. Controlled amounts of protein, sodium, phosphorus, calcium, potassium, and fluids may be prescribed; may also need modifica- tion in fiber, cholesterol, and fat based on individual requirements; clients on perito- neal dialysis usually have diets prescribed that are less restrictive with fluid and protein intake than those on hemodialysis. b. Most clients receiving dialysis need to restrict fluids (Box 11-5). c. Monitor weight daily as a priority because weight is an important indicator of fluid status. An initial assessment includes identifying allergies and food and medication interactions. O. Potassium-modified diet (see Box 11-2) 1. Indications a. Low-potassium diet is indicated for hyperka- lemia, which may be caused by impaired renal function, hypoaldosteronism, Addi- son’s disease, angiotensin-converting enzyme inhibitor medications, immunosuppressive medications, potassium-retaining diuretics, and chronic hyperkalemia. b. High-potassium diet is indicated for hypo- kalemia, which may be caused by renal tubular acidosis, gastrointestinal losses (diarrhea, vomiting), intracellular shifts, potassium-losing diuretics, antibiotics, mineralocorticoid or glucocorticoid excess resulting from primary or secondary aldoste- ronism, Cushing’s syndrome, or exogenous corticosteroid use. 2. Nursing considerations a. Foods that are low in potassium include applesauce, green beans, cabbage, lettuce, peppers, grapes, blueberries, cooked summer squash, cooked turnip greens, pineapple, and raspberries. b. Box 11-2 lists foods that are high in potassium. P. High-calcium diet 1. Indication: Calcium is needed during bone growth and in adulthood to prevent osteo- porosis and to facilitate vascular contraction, vasodilation, muscle contraction, and nerve transmission. 2. Nursing considerations a. Primary dietary sources of calcium are dairy products (see Box 11-2 for food items high in calcium). b. Lactose-intolerant clients should incorporate nondairy sources of calcium into their diet regularly. Q. Low-purine diet 1. Indication: Used for gout, kidney stones, and ele- vated uric acid levels 2. Nursing considerations a. Purine is a precursor for uric acid, which forms stones and crystals. b. Foods to restrict include anchovies, herring, mackerel, sardines, scallops, organ meats, gravies, meat extracts, wild game, goose, and sweetbreads. R. High-iron diet 1. Indication: Used for clients with anemia 2. Nursing considerations a. The high-iron diet replaces iron deficit from inadequate intake or loss. b. The diet includes organ meats, meat, egg yolks, whole-wheat products, dark green leafy vegetables, dried fruit, and legumes. c. Inform the client that concurrent intake of Vitamin C with iron foods enhances absorp- tion of iron. IV. Vegan and Vegetarian Diets A. Vegan 1. Vegans follow a strict vegetarian diet and con- sume no animal foods. 2. Eat only foods of plant origin (e.g., whole or enriched grains, legumes, nuts, seeds, fruits, vegetables). 3. The use of soybeans, soy milk, soybean curd (tofu), and processed soy protein products enhance the nutritional value of the diet. B. Lacto-vegetarian 1. Lacto-vegetarians eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs. 2. A diet of whole or enriched grains, legumes, nuts, seeds, fruits, and vegetables in sufficient quantities to meet energy needs provides a balanced diet. BOX 11-5 Measures to Relieve Thirst ▪ Chew gum or suck hard candy. ▪ Freeze fluids so they take longer to consume. ▪ Add lemon juice to water to make it more refreshing. ▪ Gargle with refrigerated mouthwash. 129 CHAPTER 11 Nutrition
- 148. C. Lacto-ovo-vegetarian 1. Lacto-ovo-vegetarians follow a food pattern that allows for the consumption of dairy products and eggs. 2. Consumption of adequate plant and animal food sources that excludes meat, poultry, pork, and fish poses no nutritional risks. D. Ovo-vegetarians: The only animal foods that the ovo-vegetarian consumes are eggs, which are an excellent source of complete proteins. E. Nursing considerations 1. Vegan and vegetarian diets are not usually pre- scribed but are a diet choice made by a client. 2. Ensure that the client eats a sufficient amount of varied foods to meet nutrient and energy needs. 3. Clients should be educated about consuming complementary proteins over the course of each day to ensure that all essential amino acids are provided. 4. Potential deficiencies in vegetarian diets include energy, protein, vitamin B12, zinc, iron, calcium, omega-3 fatty acids, and vitamin D (if limited exposure to sunlight). 5. To enhance absorption of iron, vegetarians should consume a good source of iron and vita- min C with each meal. 6. Foods eaten may include tofu, tempeh, soy milk and soy products, meat analogs, legumes, nuts and seeds, sprouts, and a variety of fruits and vegetables. 7. Soy protein is considered equivalent in quality to animal protein. Body mass index (BMI) can be calculated by dividing the client’s weight in kilograms by height in meters squared. For example, a client who weighs 75 kg (165 pounds) and is 1.8 m (5 feet, 9 inches) tall has a BMI of 23.15 (75 divided by 1.82 ¼23.15). From: Potter et al. (2013), p. 1008. V. Enteral Nutrition A. Description: Provides liquefied foods into the gastro- intestinal tract via a tube B. Indications 1. When the gastrointestinal tract is functional but oral intake is not meeting estimated nutrient needs 2. Used for clients with swallowing problems, burns, major trauma, liver or other organ failure, or severe malnutrition C. Nursing considerations 1. Clients with lactose intolerance need to be placed on lactose-free formulas. 2. See Chapter 20 for information regarding the administration of gastrointestinal tube feedings and associated complications. CRITICALTHINK ING W hat Should Y ou Do? Answer: The client with acute kidneyinjurymaybe placed on fluid restriction because of decreased renal function and glomerular filtration rate, resulting in fluid volume excess. To allow the kidneys to rest, decreased fluid consumption maybe indicated. When a client is placed on this restriction, increased thirst maybe a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, freezing fluids so they take longer to consume, adding lemon juice to water to make it more refreshing, and gargling with refrigerated mouthwash. References: Lewis et al. (2014), p. 1115; Potter et al. (2013), p. 904. P RAC TI CE Q U ES TI O N S 77. The nurse is teaching a client who has iron defi- ciency anemia about foods she should include in the diet. The nurse determines that the client under- stands the dietary modifications if which items are selected from the menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables 78. The nurse is planning to teach a client with malab- sorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1. Oranges 2. Broccoli 3. Margarine 4. Cream cheese 5. Luncheon meats 6. Broiled haddock 79. The nurse instructs a client with chronic kidney dis- ease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice 3. Bacon, cantaloupe melon, tomato juice 4. Cured pork, grits, strawberries, orange juice 80. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides die- tary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? F u n d a m e n t a l s 130 UNIT III Nursing Sciences
- 149. 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E 81. A client with hypertension has been told to main- tain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2. Boiled shrimp 3. Instant oatmeal 4. Summer squash 82. Apostoperative client has been placed on a clear liq- uid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables 83. The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1. Apples 2. Bananas 3. Smoked sausage 4. Steamed vegetables 84. A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse should offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Ice pop 85. Aclient is recovering from abdominal surgery and has a large abdominal wound. The nurse should encour- age the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken 86. The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1. Milk 2. Chicken 3. Broccoli 4. Legumes AN S WERS 77. 4 Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C. Test-Taking Strategy: Focus on the subject, diet choices for a client with anemia. Think about the pathophysiology of ane- mia and determine that the client needs foods high in iron and recall that vitamin C enhances iron absorption. Use knowledge of foods high in iron and vitamin C. Remember that green leafy vegetables are high in iron and oranges are high in vitamin C. Review: Food sources of vitamin C and iron Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Client Education; Nutrition References: Lewis et al. (2014), p. 889; Nix (2013), pp. 108, 144. 78. 3, 4, 5 Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods. Test-Taking Strategy: Focus on the subject of the question, the high-fat foods. Oranges and broccoli (fruit and vegetable) can be eliminated first. Next eliminate haddock because it is a broiled food. Remember that margarine, cheese, and luncheon meats are high in fat content. Review: High-fat foods Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Nutrition Priority Concepts: Client Education; Nutrition Reference: Nix (2013), p. 38. 79. 1 Rationale: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which F u n d a m e n t a l s 131 CHAPTER 11 Nutrition
- 150. is indicated in the correct option. The food items in the remain- ing options are high in sodium, phosphorus, or potassium. Test-Taking Strategy: Focus on the subject, dietary modifica- tion for a client with chronic kidney disease. Think about the pathophysiology of this disorder to recall that sodium needs to be limited. Noting the items sausage, bacon, and cured pork will assist in eliminating these options. Review: Dietary guidelines for the client with chronic kid- ney disease Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Client Education; Nutrition Reference: Lewis et al. (2014), pp. 1114–1115. 80. 2 Rationale: Vegans do not consume any animal products. Vita- min B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and Eare found in fresh fruits and vegetables, which are consumed in a vegan diet. Test-Taking Strategy: Focus on the subject, a vegan diet and the vitamin lacking in this diet. Recalling the food items eaten and restricted in this diet will direct you to the correct option. Remember that vegans do not consume any animal products and as a result may be deficient in vitamin B12. Review: The vegan diet and sources of vitamins Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition References: Lewis et al. (2014), p. 889; Nix (2013), p. 55. 81. 4 Rationale: Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state “low sodium.” Saltwater fish and shellfish are high in sodium. Test-Taking Strategy: Focus on the subject, foods low in sodium. Begin to answer this question by eliminating boiled shrimp, recalling that saltwater fish and shellfish are high in sodium. Next, eliminate tomato soup and instant oatmeal because they are processed foods. Review: Foods high in sodium Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition Reference: Nix (2013), pp. 141, 389. 82. 1, 2, 3 Rationale: A clear liquid diet consists of foods that are rela- tively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet. Test-Taking Strategy: Focus on the subject, a clear liquid diet. Recalling that a clear liquid diet consists of foods that are rela- tively transparent to light and are clear will assist in answering the question. Review: Clear liquid diet and full liquid diet Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition Reference: Perry, Potter, Ostendorf (2014), p. 765. 83. 3 Rationale: Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and veg- etables, which are low in sodium. Test-Taking Strategy: Note the subject, the food item that is high in sodium. Remember that smoked foods are high in sodium. Also eliminate options 1, 2, and 4 because they are comparable or alike and are nonprocessed foods. Review: Food items high in sodium Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition Reference: Nix (2013), p. 389. 84. 3 Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. Aclear liquid diet consists of foods that are rel- atively transparent. The food items in the incorrect options are clear liquids. Test-Taking Strategy: Focus on the subject, a full liquid item. Remember that a clear liquid diet consists of foods that are rel- atively transparent. This will assist you in eliminating tea, gela- tin, and ice pops; in addition, these are comparable or alike options. Review: Clear liquid diet and full liquid diet Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition Reference: Perry, Potter, Ostendorf (2014), p. 765. 85. 2 Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins. Test-Taking Strategy: Note the subject, food items naturally high in vitamin C. It is necessary to recall that citrus fruits and juices are high in vitamin C; this will direct you to the cor- rect option. F u n d a m e n t a l s 132 UNIT III Nursing Sciences
- 151. Review: Food items high in vitamin C Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Nutrition; Tissue Integrity Reference: Nix (2013), pp. 108, 451. 86. 4 Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Legumes are especially rich in this vitamin. Other good food sources include nuts, whole-grain cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid. Test-Taking Strategy: Note the strategic word, best. This may indicate that more than one option may be a food that contains thiamine. Remembering that legumes are especially rich in thiamine will direct you to the correct option. Review: Food items high in thiamine Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Fundamentals of Care—Nutrition Priority Concepts: Health Promotion; Nutrition References: Lewis et al. (2014), pp. 1023–1024; Nix (2013), p. 109. F u n d a m e n t a l s 133 CHAPTER 11 Nutrition
- 152. F u n d a m e n t a l s CH AP TER 12 Parenteral Nutrition PRIORITYCONCEPTS Fluids and Electrolytes; Nutrition CRITICALTHINK ING W hat Should Y ou Do? A client has a triple-lumen central venous catheter that is being used for the administration of parenteral nutrition, medications, and laboratory draws. The nurse is preparing to administer medication through the catheter, and the port being used for medication administration is sluggish and not flushing properly. What should the nurse do? Answer located on p. 138. I. Parenteral Nutrition (PN) A. Description 1. Parenteral nutrition (also termed hyperalimenta- tion) supplies nutrients via the veins. 2. PN consists of both partial parenteral nutrition (PPN) and total parenteral nutrition (TPN). The indication of the type used depends on the cli- ent’s nutritional needs. 3. PN supplies carbohydrates in the form of dex- trose, fats in an emulsified form, proteins in the form of amino acids, vitamins, minerals, electrolytes, and water. 4. PN prevents subcutaneous fat and muscle protein from being catabolized by the body for energy. 5. PN solutions are hypertonic due to the higher concentrations of glucose and addition of amino acids. B. Indications 1. Clients with severely dysfunctional or nonfunc- tional gastrointestinal tracts who are unable to process nutrients may benefit from PN. 2. Clients who can take some oral nutrition, but not enough to meet their nutrient requirements, may benefit from PN. 3. Clients with multiple gastrointestinal surgeries, gastrointestinal trauma, severe intolerance to enteral feedings, or intestinal obstructions, or who need to rest the bowel for healing, may ben- efit from PN. 4. Clients with severe nutritionally deficient condi- tions such as acquired immunodeficiency syn- drome, cancer, burn injuries, or malnutrition, or clients receiving chemotherapy, may benefit from PN. PN is a form of nutrition and is used when there is no other nutritional alternative. Administering nutrition orally or through a nasogastric tube is usually initiated first, before PN is initiated. C. Administration of PN (Fig. 12-1) 1. Partial parenteral nutrition a. PPN: Usually administered through a large dis- tal vein in the arm with a standard peripheral intravenous(IV) catheter or midline or through a peripherally inserted central catheter (PICC). A midline is placed in an upper arm vein such as the brachial or cephalicvein with the tip end- ing below the level of the axillary line. b. If a PICC cannot be established, the subcla- vian vein or internal or external jugular veins can be used for PPN. 2. TPN: Administered through a central vein; the use of a PICC is acceptable. Other sites that can be used include the subclavian vein and the internal or external jugular veins. 3. If the bag of intravenous solution is empty and the nurse is waiting for the delivery of a new bag of solution from the pharmacy, a 10 % dex- trose in water solution should be infused at prescribed rate to prevent hypoglycemia; the pre- scribed solution should be obtained as soon as possible. The delivery of hypertonic solutions into peripheral veins can cause sclerosis, phlebitis, or swelling. Monitor closely for these complications. II. Components of Parenteral Nutrition A. Carbohydrates 1. The strength of the dextrose solution depends on the client’s nutritional needs, the route of 134
- 153. administration (central or peripheral), and agency protocols. 2. Carbohydrates typically provide 60% to 70% of calorie (energy) needs. B. Amino acids (protein) 1. Concentrations range from 3.5% to 20%; lower concentrations are most commonly used for peripheral vein administration and higher con- centrations are most often administered through a central vein. 2. About 15% to 20% of total energy needs should come from protein. C. Fat emulsion (lipids) 1. Lipids provide up to 30% of calorie (energy) needs. 2. Lipids provide nonprotein calories and prevent or correct fatty acid deficiency. 3. Lipid solutions are isotonic and therefore can be administered through a peripheral or central vein; the solution may be administered through a separate IV line below the filter of the main IV administration set by a Y-connector or as an admixture to the PN solution (3-in-1 admixture consisting of dextrose, amino acids, and lipids). 4. Most fat emulsions are prepared from soybean or safflower oil, with egg yolk to provide emulsifica- tion; the primary components are linoleic, oleic, palmitic, linolenic, and stearic acids (assess the client for allergies). 5. Glucose-intolerant clients or clients with diabe- tes mellitus may benefit from receiving a larger percentage of their PN from lipids, which helps to control blood glucose levels and lower insulin requirements caused by infused dextrose. 6. Examine the bottle for separation of emulsion into layers or fat globules or for the accumulation of froth; if observed, do not use and return the solution to the pharmacy. 7. Additives should not be put into the fat emulsion solution. 8. Follow agency policy regarding the filter size that should be used; usually a 1.2-µm filter or larger should be used because the lipid particles are too large to pass through a 0.22-µm filter. 9. Infuse solution at the flow rate prescribed— usually slowly at 1 mL/minute initially— monitor vital signs every 10 minutes, and observe for adverse reactions for the first 30 minutes of the infusion. If signs of an adverse reaction occur, stop the infusion and notify the health care provider (HCP) (Box 12-1). 10. If no adverse reaction occurs, adjust the flow rate to the prescribed rate. 11. Monitor serum lipids 4 hours after discontinuing the infusion. Fat emulsions (lipids) contain egg yolk phospho- lipids and should not be given to clients with egg allergies. D. Vitamins 1. PN solutions usually contain a standard multivi- tamin preparation to meet most vitamin needs and prevent deficiencies. 2. Individual vitamin preparations can be added, as needed and as prescribed. E. Mineralsand trace elements:Commercialmineral and trace element preparations are available in various concentrations to promote normal metabolism. F u n d a m e n t a l s Incision From IV feeder Subclavian vein Catheter inside superior vena cava B Superior vena cava Cephalic vein A PICC sites Peripherally inserted central catheter Basilic vein FIGURE 12-1 A, Placement of peripherally inserted central catheter through antecubital fossa. B, Placement of central venous catheter inserted into subclavian vein. IV, Intravenous; PICC, peripherally inserted central catheter. BOX 12-1 Signs and Symptoms of an Adverse Reaction to Lipids ▪ Chest and back pain ▪ Chills ▪ Cyanosis ▪ Diaphoresis ▪ Dyspnea ▪ Fever ▪ Flushing ▪ Headache ▪ Nausea and vomiting ▪ Pressure over the eyes ▪ Thrombophlebitis ▪ Vertigo 135 CHAPTER 12 Parenteral Nutrition
- 154. F u n d a m e n t a l s F. Electrolytes: Electrolyte requirements for individuals receiving PN therapy vary, depending on body weight, presence of malnutrition or catabolism, degree of electrolyte depletion, changes in organ function, ongoing electrolyte losses, and the disease process. G. Water: The amount of water needed in a PN solution is determined by electrolyte balance and fluid requirements. H. Regular insulin: May be added to control the blood glucose level because of the high concentration of glucose in the PN solution. I. Heparin: May be added to reduce the buildup of a fibrinous clot at the catheter tip. III. Administration and Discontinuation A. Types of administration 1. Continuous PN a. Infused continuously over 24 hours b. Most commonly used in a hospital setting 2. Intermittent or cyclic PN a. In general, the nutrient solution infusion reg- imen varies and is commonly administered overnight. b. Allows clients requiring PN on a long-term basis to participate in activities of daily living during the day without the inconvenience of an IV bag and pump set c. Monitor glucose levels closely because of the risk of hypoglycemia due to lack of glucose during non-infusion times. B. Discontinuing PN therapy 1. Evaluation of nutritional status by a nutritionist or pharmacist is done before PN is discontinued. 2. If discontinuation is prescribed, gradually decrease the flow rate for 1 to 2 hours while increasing oral intake (this assists in preventing hypoglycemia). 3. After removal of the IVcatheter, change the dress- ing daily until the insertion site heals. Note that central lines should not be left in without a rea- son due to risk of infection, but in some situa- tions are left in place and used for other necessary reason (venous access, medication administration). 4. Encourage oral nutrition. 5. Record oral intake, body weight, and laboratory results of serum electrolyte and glucose levels. Abrupt discontinuation of a PN solution can result in hypoglycemia. The flow rate should be decreased gradually when the PN is discontinued. IV. Complications (Table 12-1) A. Pneumothorax and air embolism are associated with central line placement; air embolism is also associ- ated with tubing changes. B. Other complications include infection (catheter- related), hypervolemia, and metabolic alterations such as hyperglycemia and hypoglycemia; these complications are usually caused by the PN solution itself (see Priority Nursing Actions). V. Additional Nursing Considerations A. Check the PN solution with the HCP’s prescription to ensure that the prescribed components are con- tained in the solution; some health care agencies require validation of the prescription by 2 registered nurses. B. To prevent infection and solution incompatibility, IV medications and blood are not given through the PN line. C. Blood for testing may be drawn from the central venous access site; a port other than the port used to infuse the PN is used for blood draws after the PN has been stopped for several minutes PRIORITYNURSING ACTIONS Central Venous Catheter Site with a Suspected Infection 1. Notify the health care provider (HCP). 2. Prepare to remove the catheter and for possible restart at a different location. 3. Remove the tip of the catheter and send it to the labora- tory for culture if prescribed by the HCP. 4. Prepare the client for obtaining blood cultures. 5. Prepare for antibiotic administration. 6. Document the occurrence, the actions taken, and the cli- ent’s response. Signs of infection at the catheter site include redness or drainage. The client will also exhibit chills, fever, and an ele- vated white blood cell count. If the nurse suspects infection, the HCP is notified because of the risk for sepsis. The cath- eter is removed and the client is prepared for a possible restart at a different location as prescribed. A central line may be removed by a nurse who has been trained in approved protocol to remove a central line. If requested, the catheter tip may be sent to the laboratory for culture to identify the bacteria present so that the effective antibiotic is prescribed. Intravenous (IV) antibiotics maybe prescribed and an IV site will be needed for administration. Blood cul- tures are also performed to determine the presence of bacte- ria in the blood. Antibiotics are not started until blood cultures are obtained; otherwise the results of the cultures maynot be accurate. Finally, the nurse documents the occur- rence, actions taken, and the client’s response. Additionally, per agencyprotocol, pictures ofthe infected catheter site may be taken and added to the documentation. References Lewis et al. (2014), p. 311; Perry, Potter, Ostendorf(2014), pp. 798, 801. 136 UNIT III Nursing Sciences
- 155. F u n d a m e n t a l s TABLE 12-1 Complications of Parenteral Nutrition Complication Possible Cause Signs or Symptoms Intervention Prevention Air embolism ▪ Catheter system opened or IVtubing disconnected ▪ Air entry on IV tubing changes ▪ Apprehension ▪ Chest pain ▪ Dyspnea ▪ Hypotension ▪ Loud churning sound heard over pericardium on auscultation ▪ Rapid and weak pulse ▪ Respiratory distress ▪ Clamp all ports of the IV catheter ▪ Place the client in a left side-lying position with the head lower than the feet ▪ Notify the HCP ▪ Administer oxygen ▪ Make sure all catheter connections are secure (use tape per agency protocol) ▪ Clamp the catheter when not in use and when changing caps (follow agency protocol for flushing and clamping the catheter and cap changes) ▪ Instruct the client in the Valsalva maneuver for tubing and cap changes ▪ For tubing and cap changes, place the client in the Trendelenburg position (if not contraindicated) with the head turned in the opposite direction of the insertion site; client should hold breath and bear down Hyperglycemia ▪ High concentration of dextrose in solution ▪ Client receiving solution too quickly ▪ Not enough insulin ▪ Infection ▪ Restlessness ▪ Confusion ▪ Weakness ▪ Diaphoresis ▪ Elevated blood glucose level > 200 mg/dL (10.9 mmol/L) ▪ Excessive thirst ▪ Fatigue ▪ Kussmaul respirations ▪ Coma (when severe) ▪ Notify the HCP ▪ The infusion rate may need to be slowed ▪ Monitor blood glucose levels ▪ Administer regular insulin as prescribed ▪ Assess the client for a history of glucose intolerance ▪ Assess the client’s medication history (corticosteroids increase blood glucose) ▪ Begin infusion at a slow rate as prescribed (usually 40-60 mL/h) ▪ Monitor blood glucose levels per agency protocol ▪ Administer regular insulin as prescribed ▪ Use strict aseptic technique to prevent infection Hypervolemia ▪ Excessive fluid administration or administration of fluid too rapidly ▪ Renal dysfunction ▪ Heart failure ▪ Hepatic failure ▪ Bounding pulse ▪ Crackles on lung auscultation ▪ Headache ▪ Increased blood pressure ▪ Jugular vein distention ▪ Weight gain greater than desired ▪ Slow or stop IV infusion ▪ Notify the HCP ▪ Restrict fluids ▪ Administer diuretics ▪ Use dialysis (in extreme cases) ▪ Assess client’s history for risk for hypervolemia ▪ Administer via an electronic infusion device and ensure proper function of the device ▪ Never increase the rate of infusion of the device to “catch up” if the infusion gets behind ▪ Monitor intake and output ▪ Monitor weight daily (ideal weight gain is 1-2 lb per week) Hypoglycemia ▪ PN abruptly discontinued ▪ Too much insulin being administered ▪ Anxiety ▪ Diaphoresis ▪ Hunger ▪ Low blood glucose level < 70 mg/dL (4 mmol/L) ▪ Shakiness ▪ Weakness ▪ Notify the HCP ▪ Administer IV dextrose ▪ Monitor blood glucose level ▪ Gradually decrease PN solution when discontinued ▪ Infuse 10% dextrose at same rate as the PN to prevent hypoglycemia for 1-2 hours after the PN solution is discontinued ▪ Monitor glucose levels and check the level 1 hour after discontinuing the PN Infection ▪ Poor aseptic technique ▪ Catheter contamination ▪ Contamination of solution ▪ Chills ▪ Fever ▪ Elevated white blood cell count ▪ Redness or drainage at insertion site ▪ Notify the HCP ▪ Remove catheter ▪ Send catheter tip to the laboratory for culture ▪ Prepare to obtain blood cultures ▪ Prepare for antibiotic administration ▪ Use strict aseptic techniques (PN solution has a high concentration ofglucose and is a medium for bacterial growth) ▪ Monitor temperature (fever could indicate infection) ▪ Assess IV site for signs of infection (redness, swelling, drainage) ▪ Change site dressing, solution, and tubing as specified by agency policy ▪ Do not disconnect tubing unnecessarily Pneumothorax ▪ Inexact catheter placement resulting in puncture of the pleural space ▪ Chest or shoulder pain ▪ Sudden shortness of breath ▪ Cyanosis ▪ Tachycardia ▪ Absence of breath sounds on affected side ▪ Notify the HCP ▪ Prepare to obtain a chest x-ray ▪ Small pneumothorax may resolve ▪ Larger pneumothorax mayrequire chest tube ▪ Monitor for signs of pneumothorax ▪ Obtain a chest x-ray after insertion of the catheter to ensure proper catheter placement ▪ PN is not initiated until correct catheter placement is verified and the absence of pneumothorax is confirmed HCP, Health care provider; IV, intravenous; PN, parenteral nutrition. Adapted from Ignatavicius D, Workman M: Medical-surgical nursing: patient-centered collaborative care, ed 7, St. Louis, 2013, Saunders. 137 CHAPTER 12 Parenteral Nutrition
- 156. (per agency procedure) because the PN solution can alter the results of the sample. The client with a cen- tral venous access site receiving PN should still have a venipuncture site. D. Monitor partial thromboplastin time and prothrom- bin time for clients receiving anticoagulants. E. Monitor electrolyte and albumin levels and liver and renal function studies, as well as any other prescribed laboratory studies. Blood studies for blood chemis- tries are normally done every other day or 3 times per week (per agency procedures) when the client is receiving PN; the results are the basis for the HCP continuing or changing the PN solution or rate. F. Monitor blood glucose levels as prescribed (usually every 4 hours) because of the risk for hyperglycemia from the PN solution components. G. In severely dehydrated clients, the albumin level may drop initially after initiating PN, because the treat- ment restores hydration. H. With severely malnourished clients, monitor for “refeeding syndrome” (a rapid drop in potassium, magnesium, and phosphate serum levels). I. The electrolyte shift that occurs in “refeeding syn- drome” can cause cardiovascular, respiratory, and neurological problems; monitor for shallow respira- tions, confusion, weakness, bleeding tendencies, and seizures. If noted, the HCP is notified immediately. J. Abnormal liver function values may indicate intoler- ance to or an excess of fat emulsion or problems with metabolism with glucose and protein. K. Abnormal renal function tests may indicate an excess of amino acids. L. PN solutions should be stored under refrigeration and administered within 24 hours from the time they are prepared (remove from refrigerator 0.5 to 1 hour before use). M. PN solutions that are cloudy or darkened should not be used and should be returned to the pharmacy. N. Additions of substances such as nutrients to PN solu- tions should be made in the pharmacy and not on the nursing unit. O. Consultation with the nutritionist should be done on a regular basis (as prescribed or per agency protocol). VI. Home Care Instructions (Box 12-2) P RAC TI CE Q U ES TI O N S 87. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which F u n d a m e n t a l s BOX 12-2 Home Care Instructions Teach the client and caregiver how to obtain, administer, and maintain parenteral nutrition fluids. Teach the client and caregiver how to change a sterile dressing. Obtain a daily weight at the same time of day in the same clothes. Stress that if a weight gain of more than 3 lb/week is noted, this may indicate excessive fluid intake and should be reported. Monitor the blood glucose level and report abnormalities immediately. Teach the client how to monitor for and man- age hypoglycemia and hyperglycemia. Teach the client and caregiver about the signs and symptoms of side effects or adverse effects such as infection, throm- bosis, air embolism, and catheter displacement. Teach the client and caregiver the actions to take if a compli- cation arises and about the importance of reporting com- plications to the health care provider. For signs and symptoms of thrombosis, the client should report edema of the arm or at the catheter insertion site, neck pain, and jugular vein distention. Leaking offluid from the insertion site or pain or discomfort as the fluids are infused may indicate displacement of the catheter; this must be reported immediately. Encourage the client and caregiver to contact the health care provider iftheyhave questions about administration or any other questions. Inform the client and caregiver about the importance of follow-up care. Teach the client to keep electronic infusion devices fully charged in case of electrical power failure. CRITICALTHINK ING W hat Should Y ou Do? Answer: Difficultywith flushing the catheter indicates that the catheter is partially or fully blocked. Possible causes of a blockage include a clamped or kinked catheter, the tip of the catheter against the vein wall, thrombosis, or a precipi- tate buildup in the lumen. The nurse should not try to force the flushing because this could dislodge a clot or disrupt the integrity of the catheter. If the catheter becomes fully blocked, it may not be usable. The nurse should assess for and alleviate clamping or kinking. The nurse should also instruct the client to change position, raise the arm, and cough. If the blockage is due to a positional issue, this inter- vention will correct it. The nurse should attempt to flush again to see if the problem has been corrected. If it has not, this difficulty should be reported to the necessary per- sonnel (i.e., health care provider or intravenous nurse) so that full functionality can be regained. Fluoroscopy may be performed to determine the cause of the blockage and anti- coagulant or thrombolytic medications may be instilled into the catheter as prescribed to alleviate blockage. References: Lewis et al. (2014), p. 312; Perry, Potter, Ostendorf (2014), p. 504. 138 UNIT III Nursing Sciences
- 157. F u n d a m e n t a l s prescription regarding the PN solution will accom- pany the diet prescription? 1. Discontinue the PN. 2. Decrease PN rate to 50 mL/hour. 3. Start 0.9% normal saline at 25 mL/hour. 4. Continue current infusion rate prescriptions for PN. 88. The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breathe normally. 2. Turn the head to the right. 3. Exhale slowly and evenly. 4. Take a deep breath, hold it, and bear down. 89. A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line cath- eter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1. On the left side, with the head lower than the feet 2. On the left side, with the head higher than the feet 3. On the right side, with the head lower than the feet 4. On the right side,with thehead higher than thefeet 90. Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? 1. Ensure that the client does not have diabetes. 2. Determine whether the client has an allergy to eggs. 3. Add regular insulin to the fat emulsion, using aseptic technique. 4. Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion. 91. The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifesta- tions of hyperglycemia? 1. Fever, weak pulse, and thirst 2. Nausea, vomiting, and oliguria 3. Sweating, chills, and abdominal pain 4. Weakness, thirst, and increased urine output 92. The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client’s temperature 2. Expiration date on the bag 3. Time of last dressing change 4. Tightness of tubing connections 93. The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? 1. Roll the bottle of solution gently. 2. Obtain a different bottle of solution. 3. Shake the bottle of solution vigorously. 4. Run the bottle of solution under warm water. 94. Aclient receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash. 2. Return them to the hospital pharmacy. 3. Save them for return to the manufacturer. 4. Prepare to send them to the laboratoryfor culture. 95. A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in mon- itoring this therapy? 1. Pulse and weight 2. Temperature and weight 3. Pulse and blood pressure 4. Temperature and blood pressure 96. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines thatwhich clientswould bethemost likelycandidates for parenteral nutrition (PN)? Select all that apply. 1. A client with extensive burns 2. A client with cancer who is septic 3. Aclient who has had an open cholecystectomy 4. A client with severe exacerbation of Crohn’s disease 5. A client with persistent nausea and vomiting from chemotherapy 97. The nurse is preparing to hang the first bag of paren- teral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution? 1. Urine test strips 2. Blood glucose meter 3. Electronic infusion pump 4. Noninvasive blood pressure monitor 98. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solu- tion should the nurse hang until another PN solu- tion is mixed and delivered to the nursing unit? 1. 5% dextrose in water 2. 10% dextrose in water 3. 5% dextrose in Ringer’s lactate 4. 5% dextrose in 0.9% sodium chloride 139 CHAPTER 12 Parenteral Nutrition
- 158. F u n d a m e n t a l s 99. The nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the infusion is1 hour behind. Which action should the nurse take? 1. Adjust the infusion rate to catch up over the next hour. 2. Increase the infusion rate to catch up over the next 2 hours. 3. Ensure that the fat emulsion infusion rate is infus- ing at the prescribed rate. 4. Adjust the infusion rate to run wide open until the solution is back on time. 100. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the pres- ence of which condition? 1. Thirst 2. Polyuria 3. Decreased blood pressure 4. Crackles on auscultation of the lungs 101. The nurse is caring for a restless client who is begin- ning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? 1. Calculate daily intake and output. 2. Monitor the temperature once daily. 3. Secure all connections in the PN system. 4. Monitor blood glucose levels every 12 hours. 102. A client receiving parenteral nutrition (PN) com- plains of a headache. The nurse notes that the cli- ent has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilater- ally. The nurse determines that the client is experiencing which complication of PN therapy? 1. Sepsis 2. Air embolism 3. Hypervolemia 4. Hyperglycemia AN S WERS 87. 2 Rationale: When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not pro- vide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia. Test-Taking Strategy: Focus on the subject, weaning the client from the PN. Recalling the effects of PN and the complications that occur will direct you to the correct option. If you can recall that a client can experience hyperglycemia when started on PN, it may help you to remember that hypoglycemia can occur if the PN is discontinued abruptly. Review: Parenteral nutrition Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Glucose Regulation; Nutrition References: Lewis et al. (2014), p. 902; Perry, Potter, Ostendorf (2014), pp. 799, 802. 88. 4 Rationale: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change. Test-Taking Strategy: Note the strategic word, essential. Recal- ling that air embolism is a complication that can occur during tubing changes and thinking about the measures that will pre- vent this complication will direct you to the correct option. Review: The procedure for parenteral nutrition bag and tub- ing change and air embolism Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety References: Ignatavicius, Workman (2013), p. 225; Perry, Potter, Ostendorf (2014), p. 798. 89. 1 Rationale: Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected. Test-Taking Strategy: Note the strategic word, immediately. Focus on the subject, the occurrence of an air embolism. Recall that the goal in this emergency situation is to trap air in the right side of the heart. Think about the position that will achieve this goal; this will direct you to the correct option. Review: Actions to take if an air embolism is suspected Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Gas Exchange; Perfusion Reference: Perry, Potter, Ostendorf (2014), p. 798. 140 UNIT III Nursing Sciences
- 159. 90. 2 Rationale: The client beginning infusions of fat emulsions must be first assessed for known allergies to eggs to prevent anaphylaxis. Egg yolk is a component of the solution and pro- vides emulsification. The remaining options are unnecessary and are not related specifically to the administration of fat emulsion. Test-Taking Strategy: Focus on the strategic word, essential, when examining each option and recall knowledge of fat emul- sions. Recall the components of fat emulsion to direct you to the correct option. Review: Fat emulsion and parenteral nutrition Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety References: Lewis et al. (2014), p. 901; Gahart, Nazareno (2015), p. 527. 91. 4 Rationale: The high glucose concentration in PN places the cli- ent at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and coma when hyperglyce- mia is severe. If the client has these symptoms, the blood glu- cose level should be checked immediately. The remaining options do not identify signs specific to hyperglycemia. Test-Taking Strategy: Focus on the subject, signs of hypergly- cemia. For an option to be correct, all of the parts of that option must be correct. Begin to answer this question by eliminating options that include fever and chills because they are indicative of infection. Choose the correct option over the option that includes oliguria because the client with hyperglycemia has increased urine output rather than decreased urine output. Review: Signs of hyperglycemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Glucose Regulation; Nutrition Reference: Perry, Potter, Ostendorf (2014), p. 798. 92. 1 Rationale: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connec- tions would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change. Test-Taking Strategy: Note the strategic word, next. This ques- tion requires that you prioritize based on the information pro- vided in the question. Also note the relationship between site appears reddened in the question and the word temperature in the correct option. Focusing on the subject of infection will direct you to the correct option. Review: Signs of infection and parenteral nutrition Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Infection Reference: Perry, Potter, Ostendorf (2014), pp. 798, 800. 93. 2 Rationale: Fat emulsion (lipids) is a white, opaque solution administered intravenously during parenteral nutrition ther- apy to prevent fatty acid deficiency. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers of fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Therefore, the remaining options are inappropriate actions. Test-Taking Strategy: Remember that options that are compa- rable or alike are not likely to be correct. With this in mind, eliminate rolling the bottle and shaking the bottle first. Select between the remaining options by recalling the significance of fat globules in the solution. Also, think about the potential adverse effect of fat globules entering the client’s bloodstream. Review: Administration of fat emulsion Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety Reference: Gahart, Nazareno (2015), p. 525. 94. 4 Rationale: When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms per HCP prescription. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued mate- rials are not discarded or returned to the pharmacy or manufacturer. Test-Taking Strategy: Identifying the subject of the question, infection, and correlating the fever with infection associated with the intravenous line should direct you to the correct option. Remember that the discontinued materials need to be cultured. Review: Parenteral nutrition and infection Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Infection References: Lewis et al. (2014), p. 899; Perry, Potter, Ostendorf (2014), p. 804 95. 2 Rationale: The client receiving PN at home should have her or his temperature monitored as a means of detecting infec- tion, which is a potential complication of this therapy. An infection also could result in sepsis because the catheter is in a blood vessel. The client’s weight is monitored as a mea- sure of the effectiveness of this nutritional therapy and to detect hypervolemia. The pulse and blood pressure are F u n d a m e n t a l s 141 CHAPTER 12 Parenteral Nutrition
- 160. important parameters to assess, but they do not relate specif- ically to the effects of PN. Test-Taking Strategy: Note the strategic word, most, which tells you that more than 1 or all of the options may be partially or totally correct. Remember also that when there are multiple parts to an option, all parts must be correct for that option to be correct. Recalling that infection and hypervolemia are compli- cations of PN and that weight is monitored as a measure of the effectiveness of this nutritional therapy will direct you to the correct option. Review: Parenteral nutrition Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Infection References: Lewis et al. (2014), p. 902; Perry, Potter, Ostendorf (2014), pp. 800, 804. 96. 1, 2, 4, 5 Rationale: PN is indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include those clients with burns, exacerbation of Crohn’s disease, and persistent nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodefi- ciency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery. Test-Taking Strategy: Note the strategic words, most likely, which tell you that the correct options are the clients who require this type of nutritional support. Use nursing knowledge of these various conditions in the options and baseline knowl- edge of the purposes of PN to make your selection. Review: Parenteral nutrition Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Nutrition Reference: Perry, Potter, Ostendorf (2014), p. 797. 97. 3 Rationale: The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose con- tent, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client’s blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution because it is not directly related to admin- istering the PN. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure. Test-Taking Strategy: Note the strategic words, most essential. They tell you that the correct option identifies the item needed to start the infusion. Visualizing the procedure for initiating PN and focusing on the strategic words will direct you to the cor- rect option. Review: Parenteral nutrition Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 801, 803. 98. 2 Rationale: The client is at risk for hypoglycemia; therefore, the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia. Test-Taking Strategy: Focus on the subject, that the client is at risk for hypoglycemia. With this in mind, you would then select the solution that minimizes this risk to the client. Also, remember that options that are comparable or alike are not likely to be correct. Each of the incorrect options represents a solution that contains 5% dextrose. Review: The nursing actions to prevent hypoglycemia in the client receiving parenteral nutrition Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Glucose Regulation; Safety Reference: Perry, Potter, Ostendorf (2014), p. 802. 99. 3 Rationale: The nurse should not increase the rate of a fat emul- sion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid over- load. The same principle (not increasing the rate) applies to parenteral nutrition or any intravenous infusion. Therefore, the remaining options are incorrect. Test-Taking Strategy: Focus on the data in the question. Remember also that options that are comparable or alike are not likely to be correct. This guides you to eliminate the options referring to catching up. Choose the correct option over running the infusion wide open, recalling that the nurse never increases the infusion rate or adjusts an infusion rate if an infu- sion is behind. Review: Safety principles related to intravenous therapy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety References: Gahart, Nazareno (2015), pp. 526–527; Lewis et al. (2014), p. 901. 100. 4 Rationale: Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week F u n d a m e n t a l s 142 UNIT III Nursing Sciences
- 161. while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, peripheral edema, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. Adecreased blood pressure is likely to be noted in deficient fluid volume. Test-Taking Strategy: Focus on the subject of the question, a weight gain of 5 lb in 1 week, and note the strategic word, next. This should direct your thinking to the potential for hyper- volemia. With this in mind, select the option that identifies the sign of hypervolemia. Review: Signs and symptoms of hypervolemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 292. 101. 3 Rationale: The nurse should plan to secure all connections in the tubing (connections are used per agency protocol). This helps to prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitor- ing the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addi- tion, the client’s temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively. Test-Taking Strategy: Focus on the subject, safety, and note the words restless, ensure, prevent, and injury. This will direct you to the correct option. Review: Precautions related to parenteral nutrition Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Safety Reference: Lewis et al. (2014), pp. 899, 901. 102. 3 Rationale: Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rap- idly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client’s signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indi- cate sepsis, air embolism, or hyperglycemia. Test-Taking Strategy: Focus on the subject, a complication of PN, and on the data in the question. Recalling the signs of hypervolemia will direct you to the correct option. Review: Signs of hypervolemia Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Critical Care—Parenteral Nutrition Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 292. F u n d a m e n t a l s 143 CHAPTER 12 Parenteral Nutrition
- 162. F u n d a m e n t a l s CH AP TER 13 Intravenous Therapy PRIORITYCONCEPTS Fluids and Electrolytes; Safety CRITICALTHINK ING W hat Should Y ou Do? Aclient with a peripherallyinserted central catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dys- pnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do? Answer located on p. 153. I. Intravenous Therapy A. Purpose and uses 1. Used to sustain clients who are unable to take substances orally 2. Replaces water, electrolytes, and nutrients more rapidly than oral administration 3. Provides immediate access to the vascular system for the rapid delivery of specific solutions with- out the time required for gastrointestinal tract absorption 4. Provides a vascular route for the administration of medication or blood components B. Types of solutions (Table 13-1) 1. Isotonic solutions a. Have the same osmolality as body fluids b. Increase extracellular fluid volume c. Do not enter the cells because no osmotic force exists to shift the fluids 2. Hypotonic solutions a. Are more dilute solutions and have a lower osmolality than body fluids b. Cause the movement of water into cells by osmosis c. Should be administered slowly to prevent cellular edema 3. Hypertonic solutions a. Are more concentrated solutions and have a higher osmolality than body fluids b. Cause movement of water from cells into the extracellular fluid by osmosis 4. Colloids a. Also called plasma expanders b. Pull fluid from the interstitial compartment into the vascular compartment c. Used to increase the vascular volume rapidly, such as in hemorrhage or severe hypovolemia Administration ofan intravenous (IV) solution ormed- ication provides immediate access to the vascular system. This is a benefit ofadministering solutions or medications via this route but can also present a risk. Therefore, it is critical to ensure that the health care provider’s (HCP’s) prescriptions are checked carefully and that the correct solution or medication is administered as prescribed. Always follow the 6 rights for medication administration. II. Intravenous Devices A. IV cannulas 1. Butterfly sets a. The set is a wing-tip needle with a metal can- nula, plastic or rubber wings, and a plastic catheter or hub. b. The needle is 0.5 to 1.5 inches in length, with needle gauge sizes from 16 to 26. c. Infiltration is more common with these devices. d. The butterfly infusion set is used commonly in children and older clients, whose veins are likely to be small or fragile. 2. Plastic cannulas a. Plastic cannulas may be an over-the-needle device or an in-needle catheter and are used primarily for short-term therapy. b. Theover-the-needledeviceispreferred forrapid infusion and ismore comfortable for the client. c. The in-needle catheter can cause catheter embolism if the tip of the cannula breaks. B. IV gauges 1. The gauge refers to the diameter of the lumen of the needle or cannula. 2. The smaller the gauge number, the larger the diameter of the lumen; the larger the gauge num- ber, the smaller the diameter of the lumen. 144
- 163. F u n d a m e n t a l s 3. The size of the gauge used depends on the solu- tion to be administered and the diameter of the available vein. 4. Large-diameter lumens (smaller gauge numbers) allow a higher fluid rate than smaller diameter lumens and allow the administration of higher concentrations of solutions. 5. For rapid emergency fluid administration, blood products, or anesthetics, preoperative and post- operative clients, large-diameter lumen needles or cannulas are used, such as an 18- or 19-gauge lumen or cannula. 6. For peripheral fat emulsion (lipids) infusions, a 20- or 21-gauge lumen or cannula is used. 7. For standard IV fluid and clear liquid IV medica- tions, a 22- or 24-gauge lumen or cannula is used. 8. If the client has very small veins, a 24- to 25- gauge lumen or cannula is used. C. IV containers 1. Container may be glass or plastic. 2. Squeeze the plastic bag to ensure intactness and assessthe glassbottle for anycracksbefore hanging. 3. Reconstitute any medications per agency proto- col and pharmacy instruction. Do not write on a plastic IVbag with a marking pen because the ink may be absorbed through the plastic into the solution. Use a label and a ballpoint pen for writ- ing on the label, placing the label onto the bag. D. IV tubing (Fig. 13-1) 1. IVtubing contains a spike end for the bag or bot- tle, drip chamber, roller clamp, Y site, and adapter end for attachment to the cannula or needle that is inserted into the client’s vein. 2. Shorter, secondary tubing is used for piggyback solutions, connecting them to the injection sites nearest to the drip chamber (Fig. 13-2). 3. Special tubing is used for medication that absorbs into plastic (check specific medication administration guidelines when administering IV medications). 4. Vented and nonvented tubing are available. a. A vent allows air to enter the IV container as the fluid leaves. b. Avented adapter can be used to add a vent to a nonvented IV tubing system. c. Use nonvented tubing for flexible containers. TABLE 13-1 Types of Intravenous Solutions Solution and Type Uses 0.9% saline (NS): Isotonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic acid-base imbalances. Used before or after the infusion of blood products. Ringer’s lactate solution: Isotonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea. 5% dextrose in water (D5W): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarity or tonicity of the nondextrose components (electrolytes) within the water (may become hypotonic). Replaces deficits of total body water. Not used alone to expand extracellular fluid volume because dilution of electrolytes can occur. 5% dextrose in 0.225% saline (5% D/1/4 NS): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarityor tonicityofthe nondextrose components (electrolytes) within the water (may become hypertonic). Used as initial fluid for hydration because it provides more water than sodium. Commonly used as maintenance fluid. 5% dextrose in 0.9% saline (5% D/NS): Hypertonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic alkalosis. 5% dextrose in 0.45% saline (5% D/1/2 NS): Hypertonic Used as initial fluid for hydration because it provided more water than sodium. Commonly used as maintenance fluid. 5% dextrose in Ringer’s lactate solution: Hypertonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea. Spike end for IV bag or bottle Drip chamber Roller clamp Adapter end of tubing to needle Y site FIGURE 13-1 Intravenous (IV) tubing. 145 CHAPTER 13 Intravenous Therapy
- 164. F u n d a m e n t a l s d. Use vented tubing for glass or rigid plastic containers to allow air to enter and displace the fluid as it leaves; fluid will not flow from a rigid IV container unless it is vented. Extension tubing can be added to an IVtubing set to provide extra length to the tubing. Add extension tubing to the IVtubing set for children, clients who are restless, or clients who have special mobility needs. E. Drip chambers (Fig. 13-3) 1. Macrodrip chamber a. The chamber is used if the solution is thick or is to be infused rapidly. b. The drop factor varies from 10 to 20 drops (gtt)/mL, depending on the manufacturer. c. Read the tubing package to determine how many drops per milliliter are delivered (drop factor). 2. Microdrip chamber a. Normally, the chamber has a short vertical metal piece (stylet) where the drop forms. b. The chamber delivers about 60 gtt/mL. c. Read the tubing package to determine the drop factor (gtt/mL). d. Microdrip chambers are used if fluid will be infused at a slow rate (less than 50 mL/hour) or if the solution contains potent medication that needs to be titrated, such as in a critical care setting or in pediatric clients. F. Filters 1. Filters provide protection by preventing particles from entering the client’s veins. 2. They are used in IV lines to trap small particles such as undissolved substances, or medications that have precipitated in solution. 3. Check the agency policy regarding the use of filters. 4. A0.22-µm filter is used for most solutions; a 1.2- µm filter is used for solutions containing lipids or albumin; and a special filter is used for blood components. 5. Change filters every 24 to 72 hours (depending on agency policy) to prevent bacterial growth. G. Needleless infusion devices 1. Needleless infusion devices include recessed nee- dles, plastic cannulas, and 1-way valves; these systems decrease the exposure to contaminated needles. 2. Do not administer parenteral nutrition or blood products through a 1-way valve. H. Intermittent infusion devices 1. Intermittent infusion devices are used when intravascular accessibility is desired for intermit- tent administration of medications by IVpush or IV piggyback. 2. Patency is maintained by periodic flushing with normal saline solution (sodium chloride and nor- mal saline are interchangeable names). 3. Depending on agency policy, when administer- ing medication, flush with 1 to 2 mL of normal saline to confirm placement of the IV cannula; administer the prescribed medication and then flush the cannula again with 1 to 2 mLof normal saline to maintain patency. I. Electronic IV infusion devices 1. IV infusion pumps control the amount of fluid infusing and should be used with central venous lines, arterial lines, solutions containing medica- tion, and parenteral nutrition infusions. Most agencies use IV pumps for the infusion of any IV solution. 2. A syringe pump is used when a small volume of medication is administered; the syringe that con- tains the medication and solution fits into a pump and is set to deliver the medication at a controlled rate. 3. Patient-controlled analgesia (PCA) IV bag with medication FIGURE 13-2 Secondary bag with medication. IV, Intravenous. Macrodrip 10-20 gtt/mL Microdrip 60 gtt/mL FIGURE 13-3 Macrodrip and microdrip sizes. 146 UNIT III Nursing Sciences
- 165. F u n d a m e n t a l s a. A device that allows the client to self- administer IV medication, such as an analge- sic; the client can administer doses at set inter- vals and the pump can be set to lock out doses that are not within the preset time frame to prevent overdose. b. The PCA regimen may include a basal rate of infusion along with the demand dosing, basal rate infusion alone, or demand dosing alone. c. A bolus dose can be given prior to any of the settings and should be set based on the HCP’s prescription. d. PCAsare always kept locked and setup requires the witness of another registered nurse (RN). Check electronic IV infusion devices frequently. Although these devices are electronic, this does not ensure that they are infusing solutions and medications accurately. III. Latex Allergy A. Assess the client for an allergy to latex. B. IV supplies, including IV catheters, IV tubing, IV ports (particularly IVrubber injection ports), rubber stoppers on multidose vials, and adhesive tape, may contain latex. C. Latex-safe IVsupplies need to be used for clients with a latex allergy; most agencies carry these now, but this still needs to be checked. D. See Chapter 66 for additional information regarding latex allergy. IV. Selection of a Peripheral IV Site A. Veins in the hand, forearm, and antecubital fossa are suitable sites (Fig. 13-4). B. Veins in the lower extremities (legs and feet) are not suitablefor an adult client becauseofthe risk ofthrom- bus formation and the possible poolingofmedication in areas of decreased venous return (Box 13-1). C. Veins in the scalp and feet may be suitable sites for infants. D. Assess the veins of both arms closely before selecting a site. E. Start the IVinfusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs; if infiltration occurs from the ante- cubital vein, the lower veins in the same arm usually should not be used for further puncture sites. F. Determine the client’s dominant side, and select the opposite side for a venipuncture site. G. Bending the elbow on the arm with an IVmay easily obstruct the flow of solution, causing infiltration that could lead to thrombophlebitis. H. Avoid checking the blood pressure on the arm receiv- ing the IV infusion if possible. I. Do not place restraints over the venipuncture site. J. Use an armboard as needed when the venipuncture site is located in an area of flexion. In an adult, the most frequentlyused sites for insert- ing an IVcannula or needle are the veins of the forearm because the bones of the forearm act as a natural sup- port and splint. V. Initiation and Administration of IV Solutions A. Check theIVsolution against theHCP’sprescription for the type, amount, percentage of solution, and rate of flow;follow the 6 rights for medication administration. B. Assess the health status and medical disorders of the client and identify client conditions that contraindi- cate use of a particular IV solution or IV equipment, such as an allergy to cleansing solution, adhesive materials, or latex. Check compatibility of IV solu- tions as appropriate. C. Check client’s identification and explain the proce- dure to the client; assess client’s previous experience with IV therapy and preference for insertion site. D. Wash hands thoroughly before inserting an IV line and before working with an IV line; wear gloves. E. Use sterile technique when inserting an IV line and when changing the dressing over the IV site. F. Change the venipuncture site every 72 to 96 hours in accordance with Centers for Disease Control and Pre- vention (CDC) recommendations and agency policy. G. Change the IV dressing when the dressing is wet or contaminated, or as specified by the agency policy. H. Change the IV tubing every 96 hours in accordance with CDC recommendations and agency policy or with change of venipuncture site. Cephalic vein Cephalic vein Radial vein A Basilic vein Basilic vein Median vein of forearm Median cubital vein Cephalic vein B Basilic vein Dorsal venous arch Superficial dorsal veins FIGURE13-4 Common intravenous sites. A, Inner arm. B, Dorsalsurface of hand. BOX 13-1 Peripheral Intravenous Sites to Avoid ▪ Edematous extremity ▪ An arm that is weak, traumatized, or paralyzed ▪ The arm on the same side as a mastectomy ▪ An arm that has an arteriovenous fistula or shunt for dialysis ▪ A skin area that is infected 147 CHAPTER 13 Intravenous Therapy
- 166. I. Do not let an IV bag or bottle of solution hang for more than 24 hours to diminish the potential for bacterial contamination and possibly sepsis. J. Do not allow the IVtubing to touch the floor to pre- vent potential bacterial contamination. K. See Priority Nursing Actions for instructions on inserting an IV. L. See Priority Nursing Actions for instructions on removing an IV. F u n d a m e n t a l s PRIORITYNURSING ACTIONS Inserting a Peripheral Intravenous Line 1. Check the health care provider’s (HCP’s) prescription, determine the type and size of infusion device, and prepare intravenous (IV) tubing or extension set and solution; prime IV tubing or extension set to remove air from the system; explain procedure to the client. 2. Select the vein for insertion based on vein quality, client size, and indication of IVtherapy; applytourniquet and pal- pate the vein for resilience (see Fig. 13-4). 3. Clean the skin with an antimicrobialsolution,usingan innerto outercircularmotion,oras specified bytheCenters forDisease Control and Prevention (CDC) guidelines and agencypolicy. 4. Stabilize the vein below the insertion site and puncture the skin and vein, observing for blood in the flashback chamber; when observed, lower the catheter so that it is flush with the skin and advance the catheterinto the vein (ifunsuccessful,a new sterile device is used for the next attempt at insertion). 5. Remove the tourniquet. Apply pressure above the insertion site with the middle finger of the nondominant hand and retract the stylet from the catheter; connect the end of the IV tubing or extension set to the catheter tubing, secure it, and begin IVflow. Ask the client about comfort at the site and assess site for adequate flow. 6. Tape and secure insertion site with a transparent dressing as specified byagencyprocedure; label the tubing, dressing, and solution bags clearly, indicating the date and time. 7. Document the specifics about the procedure such as num- ber of attempts at insertion; the insertion site, type and size of device, solution and flow rate, and time; and the client’s response. In addition, follow agency procedure for docu- mentation of procedure. The nurse checks the HCP’s prescription for the IVline and then determines the type and size of infusion device. The type and size are important to ensure adequate flowofthe prescribed solution.Forexample, ifa blood product is prescribed, the nurse would need to insert an appropriate catheter gauge size for blood delivery. The nurse also considers the client’s size, age, mobility, and other factors in selecting the type and size of the infusion device. The nurse prepares the appropriate IV tubing or extension set and primes the IV tubing or extension set to remove air from the system. The appropriate vein is selected, the tourniquet is applied, and the vein is checked and palpated for resilience. Strict surgical asepsis is employed and the skin is cleaned with an antimicrobial solution (as specified by agency policy), using an inner to outer circular motion. The vein is stabilized to prevent its movement and the skin is punctured. Blood in the flashback chamber indicates that the device is in the vein and when noted the catheter is carefully advanced to avoid puncture of the back wall of the vein. The tourniquet is removed, the stylet is removed from the catheter device, the IVtubingorextension set is connected,and the IVflowis started. Following assessment of the client and site, the nurse tapes and secures the site and labels the tubing,dressing,and solution bag appropriately and according to agency policy. The nurse checks the site and ensures that the solution is flowing. Finally, the nurse documents the specifics about the procedure. Reference Perry, Potter, Ostendorf(2014), pp. 697, 701-703. PRIORITYNURSING ACTIONS Removing a Peripheral Intravenous Line 1. Check the health care provider’s (HCP’s) prescription and explain the procedure to the client; ask the client to hold the extremity still during cannula or needle removal. 2. Turn offthe intravenous (IV) tubingclamp and remove the dres- sing and tape covering the site, while stabilizing the catheter. 3. Apply light pressure with sterile gauze or other material as specified by agency procedure over the site and withdraw the catheter using a slow, steady movement, keeping the hub parallel to the skin. 4. Apply pressure for 2 to 3 minutes, using dry sterile gauze (applypressure for a longer period of time if the client has a bleeding disorder or is taking anticoagulant medication). 5. Inspect the site for redness, drainage, or swelling; check the catheter for intactness. 6. Apply dressing as needed per agency policy. 7. Document the procedure and the client’s response. The nurse checks for an HCP’s prescription to remove the IV line and then explains the procedure to the client. The nurse asks the client to hold the extremitystillduringremoval.The IVtubing clamp is placed in the offposition and the dressing and tape are removed.The nurse is carefulto stabilize the catheterso that it is not pulled, resulting in vein trauma. Light pressure is applied over the site to stabilize the catheter and it is removed using a slow, steady movement, keeping the hub parallel to the skin. Pressure is applied until hemostasis occurs. The site is inspected for redness, drainage, or swelling and the catheter is checked for intactness to ensure that no part of it has broken off. Adressing is applied as needed per agency policy. Finally, the nurse documents the procedure and the client’s response. Reference Perry, Potter, Ostendorf (2014), pp. 723-724. 148 UNIT III Nursing Sciences
- 167. VI. Precautions for IV Lines A. On insertion, an IV line can cause initial pain and discomfort for the client. B. An IV puncture provides a route of entry for micro- organisms into the body. C. Medications administered by the IV route enter the blood immediately, and any adverse reactions or allergic responses can occur immediately. D. Fluid (circulatory) overload or electrolyte imbal- ances can occur from excessive or too rapid infusion of IV fluids. E. Incompatibilities between certain solutions and medications can occur. A client with heart failure or renal failure usually is not given a solution containing saline because this type of fluid promotes the retention of water and would there- fore exacerbate heart failure or renal failure byincreasing the fluid overload. VII. Complications (Table 13-2) A. Air embolism 1. Description: A bolus of air enters the vein through an inadequately primed IV line, from a loose connection, during tubing change, or during removal of the IV. 2. Prevention and interventions a. Prime tubing with fluid before use, and mon- itor for any air bubbles in the tubing. b. Secure all connections. c. Replace the IV fluid before the bag or bottle is empty. d. Monitor for signs of air embolism; if sus- pected, clamp the tubing, turn the client on the left side with the head of the bed lowered (Trendelenburg position) to trap the air in the right atrium, and notify the HCP. B. Catheter embolism 1. Description: An obstruction that results from breakage of the catheter tip during IV line inser- tion or removal 2. Prevention and interventions a. Remove the catheter carefully. b. Inspect the catheter when removed. c. If the catheter tip has broken off, place a tour- niquet as proximally as possible to the IVsite on the affected limb, notify the HCP immedi- ately, prepare to obtain a radiograph, and pre- pare the client for surgery to remove the catheter piece(s), if necessary. C. Circulatory overload 1. Description: Also known as fluid overload; results from the administration of fluids too rapidly, especially in a client at risk for fluid overload 2. Prevention and interventions a. Identify clients at risk for circulatory overload. b. Calculate and monitor the drip (flow) rate frequently. c. Use an electronic IV infusion device and fre- quently check the drip rate or setting (at least every hour for an adult). d. Add a time tape (label) to the IV bag or bottle next to the volume markings. Mark on the tape the expected hourly decrease in volume based on the mL/hour calculation (Fig. 13-5). F u n d a m e n t a l s TABLE 13-2 Signs of Complications of Intravenous Therapy Complication Signs Air embolism Tachycardia Chest pain and dyspnea Hypotension Cyanosis Decreased level of consciousness Catheter embolism Decrease in blood pressure Pain along the vein Weak, rapid pulse Cyanosis of the nail beds Loss of consciousness Circulatory overload Increased blood pressure Distended jugular veins Rapid breathing Dyspnea Moist cough and crackles Electrolyte overload Signs depend on the specific electrolyte overload imbalance Hematoma Ecchymosis, immediate swelling and leakage of blood at the site, and hard and painful lumps at the site Infection Local— redness, swelling, and drainage at the site Systemic— chills, fever, malaise, headache, nausea, vomiting, backache, tachycardia Infiltration Edema, pain, numbness, and coolness at the site; may or may not have a blood return Phlebitis Heat, redness, tenderness at the site Not swollen or hard Intravenous infusion sluggish Thrombophlebitis Hard and cordlike vein Heat, redness, tenderness at site Intravenous infusion sluggish Tissue damage Skin color changes, sloughing of the skin, discomfort at the site 149 CHAPTER 13 Intravenous Therapy
- 168. e. Monitor for signs of circulatory overload. If circulatory overload occurs, decrease the flow rate to a minimum, at a keep-vein-open rate; elevate the head of the bed; keep the client warm; assess lung sounds; assess for edema; and notify the HCP. Clients with respiratory, cardiac, renal, or liver dis- ease; older clients; and very young persons are at risk for circulatoryoverload and cannot tolerate an excessive fluid volume. D. Electrolyte overload 1. Description: An electrolyte imbalance is caused by too rapid or excessive infusion or by use of an inappropriate IV solution. 2. Prevention and interventions a. Assess laboratory value reports. b. Verify the correct solution. c. Calculate and monitor the flow rate. d. Use an electronic IV infusion device and fre- quently check the drip rate or setting (at least every hour for an adult). e. Add a time tape (label) to the IVbag or bottle (see Fig. 13-5). f. Place a red medication sticker on the bag or bottle if a medication has been added to the IV solution (see Fig. 13-5). g. Monitor for signs of an electrolyte imbalance, and notify the HCP if they occur. Lactated Ringer’s solution contains potassium and should not be administered to clients with acute kidney injury or chronic kidney disease. E. Hematoma 1. Description: The collection of blood in the tis- sues after an unsuccessful venipuncture or after the venipuncture site is discontinued and blood continues to ooze into the tissue 2. Prevention and interventions a. When starting an IV, avoid piercing the poste- rior wall of the vein. b. Do not apply a tourniquet to the extremity im- mediately after an unsuccessful venipuncture. c. When discontinuing an IV, apply pressure to the site for 2 to 3 minutes and elevate the extremity; apply pressure longer for clients with a bleeding disorder or who are taking anticoagulants. d. If a hematoma develops, elevate the extremity and apply pressure and ice as prescribed. e. Document accordingly, including taking pictures of the IV site if indicated by agency policy. F. Infection 1. Description a. Infection occurs from the entry of microor- ganisms into the body through the venipunc- ture site. b. Venipuncture interrupts the integrity of the skin, the first line of defense against infection. c. The longer the therapy continues, the greater the risk for infection. d. Infection can occur locally at the IV insertion site or systemically from the entry of microor- ganisms into the body. 2. At-risk clients a. Immunocompromised clients with diseases such as cancer, human immunodeficiency virus or acquired immunodeficiency syn- drome, those receiving biologic modifier response medications for treatment of auto- immune conditions, or status post organ transplant are at risk for infection. b. Clients receiving treatments such as chemo- therapy who have an altered or lowered white blood cell count are at risk for infection. c. Older clients, because aging alters the effec- tiveness of the immune system, are at risk for infection. d. Clients with diabetes mellitus are at risk for infection. 3. Prevention and interventions a. Assess the client for predisposition to or risk for infection. b. Maintain strict asepsis when caring for the IV site. c. Monitor for signs of local or systemic infection. F u n d a m e n t a l s FIGURE 13-5 Intravenous fluid bag with medication label and time- tape. (From Potter et al., 2013.) 150 UNIT III Nursing Sciences
- 169. d. Monitor white blood cell counts. e. Check fluid containers for cracks, leaks, cloud- iness, or other evidence of contamination. f. Change IV tubing every 96 hours in accor- dance with CDC recommendations or according to agency policy; change IV site dressing when soiled or contaminated and according to agency policy. g. Label the IV site, bag or bottle, and tubing with the date and time to ensure that these are changed on time according to agency policy. h. Ensure that the IVsolution is not hanging for more than 24 hours. i. If infection occurs, the HCP is notified; dis- continue the IV, and place the venipuncture device in a sterile container for possible culture. j. Prepare to obtain blood cultures as pre- scribed if infection occurs and document accordingly. k. Restart an IV in the opposite arm to differen- tiate sepsis (systemic infection) from local infection at the IV site. l. Document accordingly, including taking pictures of the IV site if indicated by agency policy. A client with diabetes mellitus usually does not re- ceive dextrose (glucose) solutions because the solution can increase the blood glucose level. G. Infiltration 1. Description a. Infiltration is seepage of the IVfluid out of the vein and into the surrounding interstitial spaces. b. Infiltration occurs when an access device has become dislodged or perforates the wall of the vein or when venous backpressure occurs because of a clot or venospasm. 2. Prevention and interventions a. Avoid venipuncture over an area of flexion. b. Anchor the cannula and a loop of tubing securely with tape. c. Use an armboard or splint as needed if the cli- ent is restless or active. d. Monitor the IV rate for a decrease or a cessa- tion of flow. e. Evaluate the IV site for infiltration by occlud- ing the vein proximal to the IV site. If the IV fluid continues to flow, the cannula is proba- bly outside the vein (infiltrated); if the IVflow stops after occlusion of the vein, the IVdevice is still in the vein. f. Lower the IVfluid container below the IVsite, and monitor for the appearance of blood in the IV tubing; if blood appears, the IV device is most likely in the vein. g. If infiltration has occurred, remove the IV device immediately; elevate the extremity and apply compresses (warm or cool, depend- ing on the IV solution that was infusing and the HCP’s prescription) over the affected area. h. Do not rub an infiltrated area, which can cause hematoma. i. Document accordingly, including taking pic- tures of the IV site if indicated by agency policy. H. Phlebitis and thrombophlebitis 1. Description a. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (med- ication) trauma or from a local infection. b. Phlebitis can cause the development of a clot (thrombophlebitis). 2. Prevention and interventions a. Use an IV cannula smaller than the vein, and avoid using very small veins when adminis- tering irritating solutions. b. Avoid using the lower extremities (legs and feet) as an access area for the IV. c. Avoid venipuncture over an area of flexion. d. Anchor the cannula and a loop of tubing securely with tape. e. Use an armboard or splint as needed if the cli- ent is restless or active. f. Change the venipuncture site every 72 to 96 hours in accordance with CDC recom- mendations and agency policy. g. If phlebitis occurs, remove the IV device immediately and restart it in the opposite extremity; notify the HCP if phlebitis is sus- pected, and apply warm, moist compresses, as prescribed. h. If thrombophlebitis occurs, do not irrigate the IV catheter; remove the IV, notify the HCP, and restart the IV in the opposite extremity. i. Document accordingly, including taking pic- tures if indicated by agency policy. I. Tissue damage 1. Description a. Tissues most commonly damaged include the skin, veins, and subcutaneous tissue. b. Tissue damage can be uncomfortable and can cause permanent negative effects. c. Extravasation is a form of tissue damage caused by the seepage of vesicant or irritant solutions into the tissues; this occurrence requires immediate HCP notification so that treatment can be prescribed to prevent tissue necrosis. F u n d a m e n t a l s 151 CHAPTER 13 Intravenous Therapy
- 170. F u n d a m e n t a l s 2. Prevention and interventions a. Use a careful and gentle approach when applying a tourniquet. b. Avoid tapping the skin over the vein when starting an IV. c. Monitor for ecchymosis when penetrating the skin with the cannula. d. Assessfor allergiesto tape or dressingadhesives. e. Monitor for skin color changes, sloughing of the skin, or discomfort at the IV site. f. Notify the HCP if tissue damage is suspected. g. Document accordingly, including taking pic- tures if indicated by agency policy. Always document the occurrence of a complication, assessment findings, actions taken, and the client’s response according to agency policy. VIII. Central Venous Catheters A. Description 1. Central venous catheters (Fig. 13-6) are used to deliver hyperosmolar solutions, measure central venous pressure, infuse parenteral nutrition, or infuse multiple IV solutions or medications. 2. Catheter position is determined by radiography after insertion. 3. The catheter may have a single, double, or triple lumen. 4. The catheter may be inserted peripherally and threaded through the basilic or cephalic vein into the superior vena cava, inserted centrally through the internal jugular or subclavian veins, or surgi- cally tunneled through subcutaneous tissue. 5. With multilumen catheters, more than 1 medica- tion can be administered at the same time with- out incompatibility problems, and only 1 insertion site is present. For central line insertion, tubing change, and line removal, place the client in the Trendelenburg position if not contraindicated or in the supine position, and instruct the client to perform the Valsalva maneuver to increase pressure in the central veins when the IVsystem is open. B. Tunneled central venous catheters 1. A more permanent type of catheter, such as the Hickman, Broviac, or Groshong catheter, is used for long-term IV therapy. 2. The catheter may be single lumen or multilumen. 3. The catheter is inserted in the operating room, and the catheter is threaded into the lower part of the vena cava at the entrance of the right atrium (entrance site), and tunneled under the Subclavian catheter site A B Peripherally inserted central catheter (PICC) C Femoral catheter site D Hickman catheter site E F Subclavian catheter with implantable vascular access port Implantable vascular access port Self-sealing septum Skin line Suture Fluid flow Catheter FIGURE 13-6 Central venous access sites. A, Subclavian catheter. B, Peripherally inserted central catheter (PICC). C, Femoral catheter. D, Hickman catheter. E, Subclavian catheter with implantable vascular access port. F, Implantable vascular access port. 152 UNIT III Nursing Sciences
- 171. F u n d a m e n t a l s skin to the exit site where the catheter comes out of the chest; the catheter at the exit site is secured by means of a "cuff" just under the skin at the exit site. 4. The catheter is fitted with an intermittent infu- sion device to allow access as needed and to keep the system closed and intact. 5. Patency is maintained by flushing with a diluted heparin solution or normal saline solution, depending on the type of catheter, per agency policy. C. Vascular access ports (implantable port) 1. Surgicallyimplanted under the skin, portssuch asa Port-a-Cath, Mediport, or Infusaport are used for long-term administration of repeated IV therapy. 2. For access, the port requires palpation and injec- tion through the skin into the self-sealingport with a noncoring needle, such as a Huber point needle. 3. Patency is maintained by periodic flushing with a diluted heparin solution as prescribed and as per agency policy. D. PICC line 1. The catheter is used for long-term IVtherapy, fre- quently in the home. 2. The basilic vein usually is used, but the median cubital and cephalic veins in the antecubital area also can be used. 3. The catheter is threaded so that the catheter tip may terminate in the subclavian vein or superior vena cava. 4. A small amount of bleeding may occur at the time of insertion and may continue for 24 hours, but bleeding thereafter is not expected. 5. Phlebitis is a common complication. IX. Epidural Catheter (Fig. 13-7) A. Catheter is placed in the epidural space for the administration of analgesics; this method of admin- istration reduces the amount of medication needed to control pain; therefore, the client experiences fewer side effects. B. Assess client’s vital signs, level of consciousness, and motor and sensory function of lower extremities. C. Monitor insertion site for signs of infection and be sure that the catheter is secured to the client’s skin and that all connections are taped to prevent disconnection. D. Check HCP’s prescription regarding solution and medication administration. E. For continuous infusion, monitor the electronic infusion device for proper rate of flow. F. For bolus dose administration, follow the procedure for administering bolus doses through the catheter and follow agency procedure. G. Aspiration is done before injecting medication; if more than 1 mL of clear fluid or blood returns, the medication is not injected and the HCP or anesthesi- ologist is notified immediately (catheter may have migrated into the subarachnoid space or a blood vessel). Contraindications to an epidural catheter and administration of epidural analgesia include skeletal and spinalabnormalities, bleeding disorders, use ofanti- coagulants, history of multiple abscesses, and sepsis. CRITICALTHINK ING W hat Should Y ou Do? Answer: When a client has any type of central venous cath- eter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entryof air into the circulation, all of which can lead to an embolism. Signs and symptoms that this com- plication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia. If this occurs, the nurse should clamp the catheter, place the client on the left side with the head lower than the feet (to trap the embolism in the right atrium of the heart), adminis- ter oxygen, and notify the health care provider. Reference: Ignatavicius, Workman (2016), p. 207. P RAC TI C E Q U ES TI O N S 103. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dys- pneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the health care provider (HCP). 104. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/ Skeletal vertebra Epidural catheter FIGURE 13-7 Tunneled epidural catheter. 153 CHAPTER 13 Intravenous Therapy
- 172. F u n d a m e n t a l s tazobactam. The client has one IV site. The nurse should plan to take which action first? 1. Start a second IV site. 2. Check compatibility of the medication and IV fluids. 3. Mix the prepackaged piperacillin/tazobactam per agency policy. 4. Prime the tubing with the IVsolution, and back- prime the medication. 105. The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank. Answer: ______ mL 106. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage 107. The nurse is inserting an intravenous (IV) line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily. 2. The vein is distended under the needle. 3. The client does not complain of discomfort. 4. Blood return shows in the backflash chamber of the catheter. 108. The nurse is assessing a client’s peripheral intrave- nous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. Check for the presence of blood return. 2. Remove the IV site and restart at another site. 3. Document the findings and continue to moni- tor the IV site. 4. Call the health care provider (HCP) and request that the vancomycin be given orally. 109. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IVbag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag. 2. Obtain new IV tubing. 3. Wipe the spike end of the tubing with povidone iodine. 4. Scrub the spike end of the tubing with an alco- hol swab. 110. Ahealth care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Povidone iodine swab 3. Adhesive bandage 4. Sterile 2 Â 2 gauze 111. A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebi- tis has developed. The nurse should take which actions in the care of this client? Select all that apply. 1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the health care provider (HCP). 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client’s response. 112. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be pre- scribed for this client? 1. 5% dextrose in lactated Ringer’s solution 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.45% sodium chloride (1/2 normal saline) 4. 0.225% sodium chloride (1/4 normal saline) 113. The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse deter- mines that the client needs further instructions if the client made which statement? 1. “I need to wear a MedicAlert tag or bracelet.” 2. “I need to restrict my activity while this catheter is in place.” 3. “I need to keep the insertion site protected when in the shower or bath.” 4. “I need to check the markings on the catheter each time the dressing is changed.” 114. A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results 154 UNIT III Nursing Sciences
- 173. before initiating the flow rate of the client’s intrave- nous (IV) solution at 100 mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Intake and output record 4. Chest radiology results 115. Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client’s blood pressure. Upon entering the client’s room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a com- plication should the nurse assess based on the pre- viously known data? 1. Excessive bleeding 2. Crackles in the lungs 3. Incompatibility of the infusion 4. Chest pain radiating to the left arm AN S WERS 103. 1 Rationale: The client’s symptoms are compatible with circula- tory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication. Test-Taking Strategy: Note the strategic word, first. This tells you that more than 1 or all of the options are likely to be correct actions and that the nurse needs to prioritize them according to a time sequence. You must be able to recognize the signs of cir- culatory overload. From this point, select the option that pro- vides the intervention specific to circulatory overload. Review: Nursing actions for circulatory overload Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Fluid and Electrolytes; Perfusion Reference: Ignatavicius, Workman (2016), p. 207. 104. 2 Rationale: When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV fluids currently prescribed. If the fluids and medication are incom- patible, it would then be appropriate to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid having to start another IV site. After this, the nurse should prepare the prepackaged piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-prime the medication. Back-priming prevents any medication from being lost during the priming process. Test-Taking Strategy: Note the strategic word, first. This implies a correct time sequence, and you need to prioritize. Visualize and think through the steps of hanging an IVantibi- otic or secondary medication, and make your choice accordingly. Review: Administration of an IV medication Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 568, 573-574. 105. 375 Rationale: If the IVis scheduled to run over 8 hours, the hourly rate is 125 mL/hour. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mLless than 500. Test-Taking Strategy: Focus on the subject, intravenous infu- sion calculations. Use basic principles related to dosage calcu- lation and IV administration to answer this question. Subtract 125 from 500 to yield 375. Review: Administration of intravenous medications Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamental of Care—Medication/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 106. 2, 3, 4 Rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IVsolution will stop, and if an elec- tronic pump is being used, it will alarm. Erythema can be asso- ciated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent drainage is associated with phlebitis and infection. Test-Taking Strategy: Focus on the subject, clinical manifes- tations at the IV site. Remember that pallor, coolness, pain, numbness, and swelling are signs of infiltration, and that infec- tion, phlebitis, and thrombosis are associated with warmth at the IV site. Review: Signs of infiltration Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Medications and Intravenous Therapy F u n d a m e n t a l s 155 CHAPTER 13 Intravenous Therapy
- 174. Priority Concepts: Clinical Judgment; Tissue Integrity Reference: Ignatavicius, Workman (2016), p. 204. 107. 4 Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and if further distention occurs after venipuncture, this could mean the needle went through the vein and into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return. Test-Taking Strategy: Focus on the subject of the question, correct placement of an IV catheter. Noting the words blood return in the correct option will direct you to this option because a blood return is expected if the catheter is in a vein. Review: Insertion of an intravenous catheter Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Perfusion Reference: Perry, Potter, Ostendorf (2014), pp. 703-704. 108. 2 Rationale: Phlebitis at an IV site can be distinguished by cli- ent discomfort at the site and by redness, warmth, and swell- ing proximal to the catheter. If phlebitis occurs, the nurse should remove the IV line and insert a new IV line at a differ- ent site, in a vein other than the one that has developed phle- bitis. Checking for the presence of blood return should be done before the administration of vancomycin because this medication is a vesicant. Documenting the findings and con- tinuing to monitor the IV site and calling the HCP and requesting that the vancomycin be given orally do not address the immediate problem. Additionally, there could be indica- tions for the prescription of IVas opposed to oral vancomycin for the client. The HCP should be notified of the complica- tions with the IV site, but not asked for a prescription for oral vancomycin. Test-Taking Strategy: Note the strategic word, best. Also, determine if an abnormality exists. Based on the assessment findings noted in the question, it is clear that an abnormality does exist, so eliminate documenting and continuing to mon- itor. Next, recalling the appropriate nursing intervention for phlebitis will direct you to the correct option. Review: Signs and symptoms of phlebitis and the associated nursing interventions Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Tissue Integrity Reference: Ignatavicius, Workman (2016), p. 205. 109. 2 Rationale: The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infec- tion to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag. Test-Taking Strategy: Focus on the subject, that the tubing was contaminated. Use knowledge of basic infection control measures and IV therapy concepts to answer this question. Remember that if an item is contaminated, discard it and obtain a new sterile item. Review: Surgical aseptic technique Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Infection Reference: Perry, Potter, Ostendorf (2014), p. 700. 110. 4 Rationale: A dry sterile dressing such as a sterile 2 Â 2 gauze is used to apply pressure to the discontinued IVsite. This material is absorbent, sterile, and nonirritating. Apovidone iodine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred. Test-Taking Strategy: Focus on the subject, care to the IV site after removal of the catheter, and note the words applying pressure. Visualize this procedure, thinking about each of the items identified in the options to direct you to the correct option. Review: Intravenous catheter removal Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Clotting Reference: Perry, Potter, Ostendorf (2014), p. 723. 111. 1, 2, 3, 5 Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client’s response. Test-Taking Strategy: Focus on the subject, actions to take if phlebitis occurs. Recall that phlebitis is an inflammation of the vein. This will assist in eliminating the option that indicates to use the same vein because an IVshould be restarted in a vein other than the one that has developed phlebitis. Review: Phlebitis F u n d a m e n t a l s 156 UNIT III Nursing Sciences
- 175. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Inflammation Reference: Ignatavicius, Workman (2016), p. 205. 112. 1 Rationale: For this client, the goal of therapy is to expand intra- vascular volume as quickly as possible. In this situation, the cli- ent will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. There- fore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in lactated Ringer’s (hypertonic) solution would increase intravascular volume and immedi- ately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pres- sure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis. Test-Taking Strategy: Focus on the subject, that the client has been in a traumatic accident. Also, note the strategic words, most likely. Also note that the incorrect options are comparable or alike and include a % of normal saline. Determining that this client will likely experience decreased intravascular volume and blood pressure due to blood loss and recalling IV fluid types and how hypotonic and hypertonic solutions function within the intravascular space will direct you to the correct option. Review: Intravenous fluids Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Perfusion Reference: Perry, Potter, Ostendorf (2014), p. 694. 113. 2 Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should carry or wear a MedicAlert identification and should protect the site during bathing to prevent infection. The client should check the markings on the catheter during each dressing change to assess for catheter migration or dislodgement. Test-Taking Strategy: Note the strategic words, needs further instructions. These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the PICC is for long-term use will assist in directing you to the correct option. To restrict activity with such a catheter is unreasonable. Review: Peripherally inserted intravenous catheters Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Client Education; Functional Ability Reference: Perry, Potter, Ostendorf (2014), p. 735. 114. 4 Rationale: Before beginning administration of IVsolution, the nurse should assess whether the chest radiology results reveal that the central catheter is in the proper place. This is necessary to prevent infusion of IVfluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure. Test-Taking Strategy: Note the subject, care to the client with a central venous catheter. Note the words insertion of a central venous catheter at the bedside. Recalling the potential complica- tions associated with the insertion of central venous catheters will direct you to the correct option. Review: Nursing actions related to central venous catheters Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Safety References: Ignatavicius, Workman (2016), pp. 190-191, 193; Perry, Potter, Ostendorf (2014), p. 735. 115. 2 Rationale: Circulatory (fluid) overload is a complication of IV therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse pre- viously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchy- mosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a com- plication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy. Test-Taking Strategy: Focus on the data in the question and note the subject, a complication. Noting that the client is experiencing rapid breathing and is coughing will assist in directing you to the correct option. Review: Signs of circulatory overload Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Critical Care—Medications and Intravenous Therapy Priority Concepts: Clinical Judgment; Perfusion Reference: Ignatavicius, Workman (2016), p. 207. F u n d a m e n t a l s 157 CHAPTER 13 Intravenous Therapy
- 176. CH AP TER 14 Administration of Blood Products PRIORITYCONCEPTS Perfusion; Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfu- sion. The client suddenly becomes apprehensive and com- plains of back pain after the first 10 minutes of administration. What should the nurse do? Answer located on p. 163. I. Types of Blood Components A. Packed red blood cells (PRBCs) 1. PBRCs are a blood product used to replace eryth- rocytes; infusion time for 1 unit is usually between 2 and 4 hours. 2. Each unit increases the hemoglobin level by 1 g/ dL (10 mmol/L) and hematocrit by 3% (0.03); the change in laboratory values takes 4 to 6 hours after completion of the blood transfusion. 3. Evaluation of an effective response is based on the resolution of the symptoms of anemia and an increase in the erythrocyte, hemoglobin, and hematocrit count. 4. Leukocyte-poor or leukocyte-depleted units are unitsin which leukocytes,proteins,andplasmahave been reduced. They are used to restore oxygen- carryingcapacityofblood and intravascularvolume. Washed red blood cells (depleted of plasma, plate- lets, and leukocytes) maybe prescribed for a client with a history of allergic transfusion reactions or those who underwent hematopoietic stem cell transplant. Leuko- cyte depletion (leukoreduction) by filtration, washing, or freezing is the process used to decrease the amount of white blood cells (WBCs) in a unit of packed cells. B. Platelet transfusion 1. Platelets are used to treat thrombocytopenia and platelet dysfunctions. a. Clients receiving multiple units of platelets can become “alloimmunized” to different platelet antigens. These clients may benefit from receiving only platelets that match their specific human leukocyte antigen (HLA). 2. Crossmatching is not required but usually is done (platelet concentrates contain few red blood cells [RBCs]). 3. The volume in a unit of platelets may vary; always check the bag for the volume of the blood component (in milliliters). 4. Platelets are administered immediately upon receipt from the blood bank and are given rap- idly, usually over 15 to 30 minutes. 5. Evaluation of an effective response is based on improvement in the platelet count, and platelet counts normally are evaluated 1 hour and 18 to 24 hours after the transfusion; for each unit of platelets administered, an increase of 5000 to 10,000 mm3 (5 to 10 Â 109 /L) is expected. C. Fresh-frozen plasma 1. Fresh-frozen plasma may be used to provide clot- ting factors or volume expansion; it contains no platelets. 2. Fresh-frozen plasma is infused within 2 hours of thawing, while clotting factors are still viable, and is infused over a period of 15 to 30 minutes. 3. Rh compatibility and ABO compatibility are required for the transfusion of plasma products. 4. Evaluation of an effective response is assessed by monitoring coagulation studies, particularly the prothrombin time and the partial thrombo- plastin time, and resolution of hypovolemia. D. Cryoprecipitates 1. Prepared from fresh-frozen plasma, cryoprecipi- tates can be stored for 1 year. Once thawed, the product must be used; 1 unit is administered over 15 to 30 minutes. 2. Used to replace clotting factors, especially factor VIII and fibrinogen 3. Evaluation of an effective response is assessed by monitoring coagulation studies and fibrinogen levels. F u n d a m e n t a l s 158
- 177. E. Granulocytes 1. May be used to treat a client with sepsis or a neu- tropenic client with an infection that is unre- sponsive to antibiotics 2. Evaluation of an effective response is assessed by monitoring the WBC and differential counts. Document the necessary information about the blood transfusion in the client’s medical record (follow agency guidelines). Include the client’s tolerance and response to the transfusion and the effectiveness of the transfusion. II. Types of Blood Donations A. Autologous 1. A donation of the client’s own blood before a scheduled procedure is an autologous donation; it reduces the risk of disease transmission and potential transfusion complications. 2. Autologous donation is not an option for a client with leukemia or bacteremia. 3. A donation can be made every 3 days as long as the hemoglobin remains within a safe range. 4. Donations should begin within 5 weeks of the transfusion date and end at least 3 days before the date of transfusion. B. Blood salvage 1. Blood salvage is an autologous donation that involves suctioning blood from body cavities, joint spaces, or other closed body sites. 2. Blood may need to be “washed,” a special pro- cess that removes tissue debris before reinfusion. C. Designated donor 1. Designated donation occurs when recipients select their own compatible donors. 2. Donation does not reduce the risk of contracting infections transmitted by the blood; however, recipients feel more comfortable identifying their donors. III. Compatibility (Table 14-1) A. Client (the recipient) blood samples are drawn and labeled at the client’s bedside at the time the blood samples are drawn; the client is asked to state his or her name, which is compared with the name on the client’s identification band or bracelet. B. The recipient’s ABO type and Rh type are identified. C. An antibody screen is done to determine the pres- ence of antibodies other than anti-A and anti-B. D. To determine compatibility, crossmatching is done, in which donor red blood cells are combined with the recipient’s serum and Coombs’serum; the crossmatch is compatible if no RBC agglutination occurs. E. The universal RBC donor is O negative; the universal recipient is AB positive. F. Clients with Rh-positive blood can receive RBC transfusion from an Rh-negative donor if necessary; however, an Rh-negative client should not receive Rh-positive blood. The donor’s blood and the recipient’s blood must be tested for compatibility. If the blood is not compatible, a life-threatening transfusion reaction can occur. IV. Infusion Pumps A. Infusion pumps may be used to administer blood products if they are designed to function with opaque solutions; special intravenous (IV) tubing is used specifically for blood products to prevent hemolysis of red blood cells. B. Always consult manufacturer guidelines for how to use the pump and compatibility for use with blood transfusions. C. Special manual pressure cuffs designed specifically for blood product administration may be used to increase the flow rate, but it should not exceed 300 mm Hg. D. Standard sphygmomanometer cuffs are not to be used to increase the flow rate because they do not exert uniform pressure against all parts of the bag. V. Blood Warmers A. Blood warmers may be used to prevent hypothermia and adverse reactions when several units of blood are being administered. B. Special warmers have been designed for this pur- pose, and only devices specifically approved for this use can be used. If blood warming is necessary, use only warming devices specifically designed and approved for warming blood products. Do not warm blood products in a micro- wave oven or in hot water. F u n d a m e n t a l s TABLE 14-1 Compatibility Chart for Red Blood Cell Transfusions Recipient Donor A B AB O A X X B X X AB X O X X X X The ABO type of the donor should be compatible with the recipient’s. Type A can receive from type Aor O; type Bfrom type Bor O; type ABcan receive from type A, B, AB, or O; type O only from type O. From Ignatavicius D, Workman ML: Medical-surgical nursing: patient-centered collaborative care, ed 7, Philadelphia, 2013, Saunders. 159 CHAPTER 14 Administration of Blood Products
- 178. VI. Precautions and Nursing Responsibilities (Box 14-1) Check the client’s identity before administering a blood product. Be sure to check the health care pro- vider’s (HCP’s) prescription, that the client has an appropriate venous access site, that crossmatching pro- cedures have been completed, that an informed consent has been obtained, and that the correct client is receiving the correct type of blood. Use barcode scanning systems per agency policy to ensure client safety. VII. Complications (Box 14-2) A. Transfusion reactions 1. Description a. A transfusion reaction is an adverse reaction that happens as a result of receiving a blood transfusion. b. Types of transfusion reactions include hemo- lytic, allergic, febrile or bacterial reactions (septicemia), or transfusion-associated graft- versus-host disease (GVHD). F u n d a m e n t a l s BOX 14-1 Precautions and Nursing Responsibilities General Precautions A large volume of refrigerated blood infused rapidly through a central venous catheter into the ventricle of the heart can cause cardiac dysrhythmias. No solution other than normal saline should be added to blood components. Medications are never added to blood components or piggy- backed into a blood transfusion. To avoid the risk of septicemia, infusions (1 unit) should not exceed the prescribed time for administration (2 to 4 hours for packed red blood cells); follow evidence-based practice guidelines and agency procedure. The blood administration set should be changed with each unit of blood, or according to agencypolicy, to reduce the risk of septicemia. Check the blood bag for the date of expiration; components expire at midnight on the daymarked on the bag unless oth- erwise specified. Inspect the blood bag for leaks, abnormal color, clots, and bubbles. Blood must be administered as soon as possible (within 20 to 30 minutes) after being received from the blood bank,because this is the maximal allowable time out of monitored storage. Never refrigerate blood in refrigerators other than those used in blood banks; if the blood is not administered within 20 to 30 minutes, return it to the blood bank. The recommended rate of infusion varies with the blood com- ponent being transfused and depends on the client’s condi- tion; generally blood is infused as quickly as the client’s condition allows. Components containing few red blood cells (RBCs) and plate- lets may be infused rapidly, but caution should be taken to avoid circulatory overload. The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed. Client Assessment Assess for any cultural or religious beliefs regarding blood transfusions. A Jehovah’s Witness cannot receive blood or blood products; this group believes that receiving a blood transfusion has eternal consequences. Ensure that an informed consent has been obtained. Explain the procedure to the client and determine whether the client has ever received a blood transfusion or experienced any previous reactions to blood transfusions. Check the client’s vital signs; assess renal, circulatory, and respiratory status and the client’s ability to tolerate intrave- nously administered fluids. If the client’s temperature is elevated, notifythe health care pro- vider (HCP) before beginning the transfusion; a fever maybe a cause for delaying the transfusion in addition to masking a possible symptom of an acute transfusion reaction. Blood Bank Precautions Blood will be released from the blood bank only to personnel specified by agency policy. The name and identification number of the intended recipient must be provided to the blood bank, and a documented permanent record of this information must be maintained. Blood should be transported from the blood bankto only1client at a time to prevent blood delivery to the wrong client. Only1unit of blood should be transported at a time, even if the client is prescribed to have more than 1 unit transfused. Client Identity and Compatibility Check the HCP’s prescription for the administration of the blood product. The most critical phase of the transfusion is confirming product compatibility and verifying client identity. Universal barcode systems for blood transfusions should be used to confirm product compatibility, client identity, and expiration. Two licensed nurses (follow agency policy) need to check the HCP’s prescription, the client’s identity, and the client’s identification band or bracelet and number, verifying that the name and number are identical to those on the blood component tag. At the bedside, the nurse asks the client to state his or her name, and the nurse compares the name with the name on the identification band or bracelet. The nurse checks the blood bag tag, label, and blood requi- sition form to ensure that ABO and Rh types are compat- ible. The nurse uses the barcode scanning system per agency policy. If the nurse notes any inconsistencies when verifying client identity and compatibility, the nurse notifies the blood bank immediately. 160 UNIT III Nursing Sciences
- 179. 2. Signs of an immediate transfusion reaction a. Chills and diaphoresis b. Muscle aches, back pain, or chest pain c. Rashes, hives, itching, and swelling d. Rapid, thready pulse e. Dyspnea, cough, or wheezing f. Pallor and cyanosis g. Apprehension h. Tingling and numbness i. Headache j. Nausea, vomiting, abdominal cramping, and diarrhea 3. Signs of a transfusion reaction in an unconscious client a. Weak pulse b. Fever c. Tachycardia or bradycardia d. Hypotension e. Visible hemoglobinuria f. Oliguria or anuria F u n d a m e n t a l s BOX 14-1 Precautions and Nursing Responsibilities—cont’d Administration of the Transfusion Maintain standard and transmission-based precautions and surgical asepsis as necessary. Insert an intravenous (IV) line and infuse normal saline; main- tain the infusion at a keep-vein-open rate. An 18- or 19-gauge IVneedle will be needed to achieve a maxi- mum flow rate of blood products and to prevent damage to RBCs; if a smaller gauge needle must be used, RBCs maybe diluted with normal saline (check agency procedure). Acentral venous catheter is an acceptable venous access option for blood transfusions; for a multilumen catheter, use the largest catheter port available or check the port size to ensure that it is adequate for blood administration. Always check the bag for the volume of the blood component. Blood products should be infused through administration sets designed specifically for blood; use a Y-tubing or straight tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumu- late during blood storage (Fig. 14-1). Premedicate the client with acetaminophen or diphenhydra- mine, as prescribed, if the client has a history of adverse reactions; if prescribed, oral medications should be admin- istered 30 minutes before the transfusion is started, and intravenously administered medications may be given immediately before the transfusion is started. Instruct the client to report anything unusual immediately. Determine the rate of infusion by the HCP’s prescription or, if not specified, by agency policy. Begin the transfusion slowlyunder close supervision; if no reac- tion is noted within the first 15 minutes, the flow can be increased to the prescribed rate. During the transfusion, monitor the client for signs and symp- toms of a transfusion reaction; the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client. If an ABO incompatibility exists or a severe allergic reaction occurs, the reaction is usually evident within the first 50 mL of the transfusion. Document the client’s tolerance to the administration of the blood product. Monitor appropriate laboratory values and document effective- ness of treatment related to the specific type of blood product. Reactions to the Transfusion If a transfusion reaction occurs, stop the transfusion, change the IVtubing down to the IVsite, keep the IVline open with normalsaline, notifythe HCP and blood bank, and return the blood bag and tubing to the blood bank. Do not leave the client alone, and monitor the client’s vital signs and monitor for any life-threatening signs or symptoms. Obtain appropriate laboratorysamples, such as blood and urine samples (free hemoglobin indicates that RBCs were hemo- lyzed), according to agency policies. FIGURE 14-1 Tubing for blood administration has an in-line filter. (From Potter et al., 2013.) BOX 14-2 Complications of a Blood Transfusion ▪ Transfusion reactions ▪ Circulatory overload ▪ Septicemia ▪ Iron overload ▪ Disease transmission ▪ Hypocalcemia ▪ Hyperkalemia ▪ Citrate toxicity 161 CHAPTER 14 Administration of Blood Products
- 180. F u n d a m e n t a l s 4. Delayed transfusion reactions a. Reactions can occur days to years after a transfusion. b. Signs include fever, mild jaundice, and a decreased hematocrit level. Staywith the client for the first 15minutes ofthe infu- sion of blood and monitor the client for signs and symp- toms of a transfusion reaction; the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client. Vital signs are monitored every30 minutes to one hour according to institutional protocol. 5. Interventions (see Priority Nursing Actions) Stop the transfusion immediatelyif a blood transfu- sion reaction is suspected. PRIORITYNURSING ACTIONS Transfusion Reaction: Nursing Interventions 1. Stop the transfusion. 2. Change the intravenous (IV) tubing down to the IV site and keep the IV line open with normal saline. 3. Notify the health care provider (HCP) and blood bank. 4. Stay with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. 5. Prepare to administer emergency medications as prescribed. 6. Obtain a urine specimen for laboratory studies (perform any other laboratory studies as prescribed). 7. Return blood bag, tubing, attached labels, and transfu- sion record to the blood bank. 8. Document the occurrence, actions taken, and the client’s response. If the client exhibits signs of a transfusion reaction, the nurse immediately stops the transfusion and changes the IVtubing down to the IVsite to prevent the entrance of addi- tional blood solution into the client. Normal saline solution is hung and infused to keep the IVline open in the event that emergencymedications need to be administered. The HCP is notified and the nurse also notifies the blood bank of the occurrence. The nurse stays with the client and monitors the client closely while other personnel obtain needed sup- plies to treat the client. As prescribed by the HCP, the nurse administers emergencymedications such as antihistamines, vasopressors, fluids, and corticosteroids. The nurse then obtains a urine specimen for laboratorystudies and anyother laboratorystudies as prescribed to check for free hemoglobin indicating that red blood cells were hemolyzed. The blood bag, tubing, attached labels, and transfusion record are returned to the blood bank so that the blood bank can check the items to determine the reason that the reaction occurred. Finally the nurse documents the occurrence, actions taken, and the client’s response. Reference Ignatavicius, Workman (2016), pp. 824-825. B. Circulatory overload 1. Description: Caused by the infusion of blood at a rate too rapid for the client to tolerate 2. Assessment a. Cough, dyspnea, chest pain, and wheezing on auscultation of the lungs b. Headache c. Hypertension d. Tachycardia and a bounding pulse e. Distended neck veins 3. Interventions a. Slow the rate of infusion. b. Place the client in an upright position, with the feet in a dependent position. c. Notify the HCP. d. Administer oxygen, diuretics, and morphine sulfate, as prescribed. e. Monitor for dysrhythmias. f. Phlebotomy also may be a method of pre- scribed treatment in a severe case. If circulatory overload is suspected, immediately slow the rate of infusion and place the client in an upright position, with the feet in a dependent position. C. Septicemia 1. Description: Occurs with the transfusion of blood that is contaminated with microorganisms 2. Assessment a. Rapid onset of chills and a high fever b. Vomiting c. Diarrhea d. Hypotension e. Shock 3. Interventions a. Notify the HCP. b. Obtain blood cultures and cultures of the blood bag. c. Administer oxygen, IVfluids, antibiotics, vaso- pressors, and corticosteroids as prescribed. D. Iron overload 1. Description: Adelayed transfusion complication that occurs in clients who receive multiple blood transfusions, such as clients with anemia or thrombocytopenia 2. Assessment a. Vomiting b. Diarrhea c. Hypotension d. Altered hematological values 3. Interventions a. Deferoxamine, administered intravenously or subcutaneously, removes accumulated iron via the kidneys. b. Urine turns red as iron is excreted after the ad- ministration of deferoxamine; treatment is dis- continued when serum iron levels return to normal. 162 UNIT III Nursing Sciences
- 181. F u n d a m e n t a l s Contact the HCP immediately if a transfusion reac- tion or a complication of blood administration arises. E. Disease transmission 1. The disease most commonly transmitted is hep- atitis C, which is manifested by anorexia, nausea, vomiting, dark urine, and jaundice; the symp- toms usually occur within 4 to 6 weeks after the transfusion. 2. Other infectious agents and diseases transmitted by blood transfusion include hepatitis B virus, human immunodeficiency virus (HIV), human herpes virus type 6, Epstein-Barr virus, human T-cell leukemia, cytomegalovirus, and malaria. 3. Donor screening has greatly reduced the risk of transmission of infectious agents; in addition, antibody testing of donors for HIV has greatly reduced the risk of transmission. F. Hypocalcemia 1. Citrate in transfused blood binds with calcium and is excreted. 2. Assess serum calcium level before and after the transfusion. 3. Monitor for signs of hypocalcemia (hyperactive reflexes, paresthesias, tetany, muscle cramps, positive Trousseau’s sign, positive Chvostek’s sign). 4. Slow the transfusion and notify the HCP if signs of hypocalcemia occur. G. Hyperkalemia 1. Stored blood liberates potassium through hemolysis. 2. The older the blood, the greater the risk of hyper- kalemia; therefore, clients at risk for hyperkale- mia, such as those with renal insufficiency or renal failure, should receive fresh blood. 3. Assess the date on the blood and the serum potassium level before and after the transfusion. 4. Monitor the potassium level and for signs and symptoms of hyperkalemia (paresthesias, weak- ness, abdominal cramps, diarrhea, and dysrhythmias). 5. Slow the transfusion and notify the HCP if signs of hyperkalemia occur. H. Citrate toxicity 1. Citrate, the anticoagulant used in blood prod- ucts, is metabolized by the liver. 2. Rapid administration of multiple units of stored blood may cause hypocalcemia and hypomagnesemia when citrate binds calcium and magnesium; this results in citrate toxicity, causing myocardial depression and coagulopathy. 3. Those most at risk include individuals with liver dysfunction or neonates with immature liver function. 4. Treatment includes slowing or stopping the transfusion to allow the citrate to be metabo- lized; hypocalcemia and hypomagnesemia are also treated with replacement therapy. CRITICALTHINK ING W hat Should Y ou Do? Answer: Signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension;tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. In the event that a transfusion reaction is suspected, the nurse should first stop the infusion. The nurse should then change the intravenous (IV) tubing down to the IVsite, keep the IVline open with nor- mal saline, notifythe health care provider and the blood bank, and return the blood bag and the tubing to the blood bank. The nurse should also collect a urine specimen. The nurse imple- ments prescriptions, stays with the client, and monitors the client closely until the client is stabilized. Reference: Ignatavicius, Workman (2016), pp. 824-825. P RAC TI C E Q U ES TI O N S 116. Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Delay hanging the blood and notify the health care provider (HCP). 4. Administer 2 tablets of acetaminophen and begin the transfusion. 117. The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? 1. “Have you ever had a transfusion before?” 2. “Why do you think that you need the transfusion?” 3. “Have you ever gone into shock for any reason in the past?” 4. “Do you know the complications and risks of a transfusion?” 118. Aclient receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 mm Hg from a baseline of 125/ 78 mm Hg. The client’s temperature is 100.8 °F 163 CHAPTER 14 Administration of Blood Products
- 182. (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction 119. The nurse determines that a client is having a trans- fusion reaction. After the nurse stops the transfu- sion, which action should be taken next? 1. Remove the intravenous (IV) line. 2. Run a solution of 5% dextrose in water. 3. Run normal saline at a keep-vein-open rate. 4. Obtain a culture of the tip of the catheter device removed from the client. 120. The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, know- ing that this tubing is manufactured with which item? Refer to figures 1-4. 1. 2. 3. 4. 121. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums 122. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag prop- erly with another nurse. Just before beginning the transfusion, the nurse should assess which pri- ority item? 1. Vital signs 2. Skin color 3. Urine output 4. Latest hematocrit level 123. The nurse has just received a prescription to trans- fuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? 1. Check a set of vital signs. 2. Order the blood from the blood bank. 3. Obtain Y-site blood administration tubing. 4. Check to be sure that consent for the transfusion has been signed. 124. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachy- cardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated. 2. Place the client in high-Fowler’s position. 3. Increase the rate ofinfusion ofintravenous fluids. 4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy. 125. The nurse, listening to the morning report, learns that an assigned client received a unit of granulo- cytes the previous evening. The nurse makes a note to assess the results of which daily serum labora- tory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count 126. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4. Packed red blood cells 127. The nurse who is about to begin a blood transfu- sion knows that blood cells start to deteriorate after F u n d a m e n t a l s 164 UNIT III Nursing Sciences
- 183. a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1. Checks the expiration date 2. Inspects for the presence of clots 3. Checks the blood group and type 4. Checks the blood identification number 5. Hangs the blood within the specified time frame per agency policy 128. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the cli- ent to take which actions to reduce the risk of pos- sible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date. 129. Aclient with severe blood loss resulting from mul- tiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood-warming device 130. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV stor- age area to hang with the blood product at the client’s bedside? 1. Lactated Ringer’s 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride 131. The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client’s vital signs, which include temperature of 97.2 °F (36.2 °C), pulse of 108 beats per minute, blood pressure of 152/ 76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1. Collect a urine sample for analysis. 2. Place the client in an upright position. 3. Compare current data to baseline data. 4. Slow the rate of the blood transfusion. AN S WERS 116. 3 Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further pre- scriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse’s scope of practice to make. The nurse needs an HCP’s prescription to administer medications to the client. Test-Taking Strategy: Eliminate all options that indicate to begin the transfusion, noting that they are comparable or alike. In addition, the options including antihistamine and acetaminophen indicate administering medication to the cli- ent, which is not done without an HCP’s prescription. Review: Nursing responsibilities related to blood transfusion Level of Cognitive Ability: Synthesizing Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety Reference: Lewis et al (2014), p. 677. 117. 1 Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous his- tory ofshock and knowledge ofcomplications and risks oftrans- fusion is not helpful because it may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion. Test-Taking Strategy: Note the strategic word,initial. Thistells you that the correct option is the best starting point for discus- sion about the transfusion therapy. Eliminate the options that have emotionally laden trigger words, including gone into shock and risks, which make them incorrect. From the remaining options,focuson the strategic word and use therapeuticcom- munication techniques to direct you to the correct option. Review: Blood transfusion procedures Level of Cognitive Ability: Applying Client Needs: Physiological Integrity F u n d a m e n t a l s 165 CHAPTER 14 Administration of Blood Products
- 184. Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety References: Ignatavicius, Workman (2016), p. 117; Perry, Potter, Ostendorf (2014), p. 31. 118. 1 Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdomi- nal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Adelayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level. Test-Taking Strategy: Focus on the subject, a complication of a blood transfusion. Noting that the client’s temperature is ele- vated will direct you to the correct option. Review: Complications of blood transfusions Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Infection Reference: Perry, Potter, Ostendorf, (2014), p. 742. 119. 3 Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider pre- scriptions. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump. Test-Taking Strategy: Note the strategic word, next. Knowing that the IVline should not be removed assists in eliminating the options directing the nurse to discontinue the device. Recalling that normal saline, not dextrose, is used when administering a unit of blood will direct you to the correct option. Review: Transfusion reactions Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), p. 741. 120. 3 Rationale: The tubing used for blood administration has an in- line filter. The filter helps to ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing (option 2) is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip (option 4), to allow blood to flow freelythrough the drip chamber. An air vent (option 1) is unnecessary because the blood bag is not made of glass. Test-Taking Strategy: Focus on the subject, intravenous tub- ing used to administer blood. Look at each option carefully and visualize the process of blood administration. Remember that tubing used for blood administration has an in-line filter. Review: Blood administration Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety References: Ignatavicius, Workman (2016), p. 822; Perry, Potter, Ostendorf (2014), p. 744. 121. 4 Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to nor- mal after infusion of granulocytes because these cells were instrumental in fighting infection in the body. Test-Taking Strategy: Use knowledge regarding the potential uses and benefits of the various types of blood product trans- fusions. Eliminate increased hematocrit and increased hemo- globin first because they are comparable or alike. From the remaining options, recalling that platelets are necessary for proper blood clotting will direct you to the correct option. Review: Types of blood products Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Clotting Reference: Ignatavicius, Workman (2016), p. 824. 122. 1 Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion. Test-Taking Strategy: Note the strategic word, priority. This tells you that more than one of the options may be partially or totally correct and that the correct option needs to be assessed for possible comparison during the transfusion. Use the ABCs— airway, breathing, and circulation—to direct you to the cor- rect option. Review: Blood transfusions Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety References: Lewis et al. (2014), pp. 677-679; Perry, Potter, Ostendorf (2014), p. 744. F u n d a m e n t a l s 166 UNIT III Nursing Sciences
- 185. 123. 4 Rationale: After receiving a prescription for a blood transfu- sion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temper- ature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank. Test-Taking Strategy: Note the strategic word, next. This word tells you that all options may be partially or totally cor- rect, and you need to choose the best next choice. The nurse should not take any procedural steps until the client has con- sented to the blood transfusion. Review: Blood transfusions Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Blood Administration Priority Concepts: Care Coordination; Health Care Law Reference: Ignatavicius, Workman (2016), pp. 226, 822. 124. 2 Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid over- load, a complication associated with blood transfusions. Plac- ing the client in a high-Fowler’s (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IVfluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be nec- essary, but positional changes take a short amount of time to do and should be initiated first. Test-Taking Strategy: Note the strategic word, first. Apply knowledge of signs and symptoms of circulatory overload and use the ABCs—airway, breathing, and circulation—to assist you with selecting the priority action. Remember that placing the client in a high-Fowler’s (upright) position will facilitate breathing. Review: Signs of circulatory overload and associated nursing actions Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Perfusion Reference: Perry, Potter, Ostendorf (2014), p. 742. 125. 4 Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symp- toms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells. Test-Taking Strategy: Note the strategic word, effectiveness. Recalling that granulocytes are a component of WBCs will assist in directing you to the correct option. In addition, note that the remaining options are comparable or alike in that these options all refer to red blood cells. Review: Types of blood products and granulocytes Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Critical Care—Blood Administration Priority Concepts: Evidence; Infection Reference: Lewis et al. (2014), p. 676. 126. 3 Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clot- ting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dys- function. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes. Test-Taking Strategy: Focus on the subject, the type of trans- fusion therapy for the client experiencing blood loss. Note the relationship between the words experienced blood loss and the word plasma correct option. Review: Fresh-frozen plasma Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Fluid and Electrolytes Reference: Lewis et al. (2014), p. 676. 127. 1, 5 Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also needs to hang the blood within the specified time frame after receiving it from the blood bank per agency policy to ensure that the blood being transfused is fresh. The blood bank keeps the blood regulated at a specific temperature, and therefore it must be infused within a speci- fied time frame once received on the unit. The nurse also notes the blood identification (unit) number, blood group and type, and client’s name, but this is not specifically related to the degradation of blood cells. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted. Again, this is not related to the degradation of blood cells over time. Test-Taking Strategy: Focus on the subject, measures to verify prior to blood administration. Note the word deteriorate. To answer this question correctly, you must know which part of the pretransfusion verification procedure relates to the freshness of the unit of blood. Keeping this in mind should direct you to the correct options. Review: Blood transfusion F u n d a m e n t a l s 167 CHAPTER 14 Administration of Blood Products
- 186. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 744-745. 128. 1, 2 Rationale: A donation of the client’s own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion com- plications. The next most effective way is to ask a family mem- ber to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supple- ments are helpful for iron deficiency anemia but are not help- ful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery. Test-Taking Strategy: Focus on the subject, reducing the risk of possible transfusion complications. Recalling that an autol- ogous transfusion is the collection of the client’s own blood and also that family donation of blood is usually effective will direct you to the correct options. Review: Blood donation procedures Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Anxiety; Safety Reference: Ignatavicius, Workman (2016), pp. 825-826. 129. 4 Rationale: If several units of blood are to be administered rap- idly, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To pre- vent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infu- sion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products. Test-Taking Strategy: Note the words rapid and reduce the risk. These words tell you that the blood will infuse quickly and that the correct option is the one that will minimize the risk of car- diac dysrhythmias. Eliminate the pulse oximeter and cardiac monitor first because these items are comparable or alike and are used to assess for rather than reduce the risk of compli- cations. From the remaining options, use knowledge related to the complications of transfusion therapy and note the relation- ship between the words several unitsof blood in the question and blood-warming device in the correct option. Review: Blood transfusions Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Critical Care—Blood Administration Priority Concepts: Perfusion; Thermoregulation Reference: Lewis et al. (2014), p. 679. 130. 2 Rationale: Sodium chloride 0.9% (normal saline) is a stan- dard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer’s is not the solution of choice with this procedure. Test-Taking Strategy: Eliminate options that contain dextrose first because they are comparable or alike. From the remain- ing options, remember that normal saline is an isotonic solu- tion and the solution compatible with RBCs. Review: Blood transfusion procedures Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety Reference: Ignatavicius, Workman (2016), p. 825. 131. 3 Rationale: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfu- sion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, and dis- tended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symp- toms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Col- lection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction. Test-Taking Strategy: Note the strategic word, initial. This word indicates that some or all of the options may be partially or totally correct, but the nurse needs to prioritize. Also, deter- mine if an abnormality exists. Noting that the client is com- plaining of cough and the vital signs are slightly abnormal should help you to determine that further assessment is needed at this time. Review: Actions to take if a blood transfusion complication is suspected Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Critical Care—Blood Administration Priority Concepts: Clinical Judgment; Safety Reference: Ignatavicius, Workman (2016), p. 825. F u n d a m e n t a l s 168 UNIT III Nursing Sciences
- 187. UNIT IV Fundamentals of Care Pyramid to Success On the NCLEX-RN® , safety and infection control con- cepts, including standard precautions and transmission- based precautions, related to client care are a priority focus. Medication or intravenous (IV) calculation ques- tions are also a focus on the NCLEX-RN examination. Fill-in-the-blank questions may require that you calculate a medication dose or an IV flow rate. Use the on-screen calculator for these medication and IVproblems and then recheck the calculation before selecting an option or typ- ing the answer. The Pyramid to Success also focuses on the proce- dures for performing a health and physical assessment of the adult client and collecting both subjective and objective data. Perioperative nursing care and monitor- ing for postoperative complications is a priority. Client safety related to positioning and ambulation, and care to the client with a tube such as a gastrointestinal tube or chest tube are important concepts addressed on the NCLEX. Because many surgical procedures are per- formed through ambulatory care units (1-day-stay units), Pyramid Points also focus on preparing the client for discharge, teaching related to the prescribed treat- ments and medications, follow-up care, and the mobili- zation of home care support services. Client Needs: Learning Objectives Safe and Effective Care Environment Acting as an advocate regarding the client’s wishes Collaboratingwith interprofessional health care members Ensuring environmental, personal, and home safety Ensuring that the client’s rights, including informed con- sent, are upheld Establishing priorities of assessments and interventions Following advance directives regarding the client’s docu- mented requests Following guidelines regarding the use of safety devices Handling hazardous and infectious materials safely Informing the client of the surgical process and ensuring that informed consent for a surgical procedure and other procedures has been obtained Knowing the emergencyresponse plan and actions to take for exposure to biological and chemical warfare agents Maintaining confidentiality Maintaining continuity of care and initiating referrals to home care and other support services Maintaining precautions to prevent errors, accidents, and injury Positioning the client appropriately and safely Preparing and administering medications, using the rights of medication administration Preventing a surgical infection Protecting the medicated client from injury Upholding the client’s rights Using equipment safely Using ergonomic principles and body mechanics when moving a client Using standard and transmission-based precautions and surgical asepsis procedures Health Promotion and Maintenance Assisting clients and families to identify environmental hazards in the home Performing home safety assessments Performing the techniques associated with the health and physical assessment of the client Providing health and wellness teaching to prevent complications Discussing high-risk behaviors and lifestyle choices Respecting lifestyle choices and health care beliefs and preferences Teaching clients and families about accident prevention Teaching clients and families about measures to be implemented in an emergency or disaster F u n d a m e n t a l s 169
- 188. Teaching clients and families about preventing the spread of infection and preventing diseases Teaching the client about prescribed medication(s) or IV therapy Psychosocial Integrity Assessing and managing the client with sensory and per- ception alterations Discussing expected body image changes and situational role changes Facilitating client and family coping Identifying support systems Identifying the cultural, religious, and spiritual factors influencing health Keeping the family informed of client progress Providing emotional support to significant others Physiological Integrity Administering medications and IV therapy safely Assessing for expected and unexpected effects of phar- macological therapy Assessing the mobility and immobility level of the client Assisting the client with activities of daily living Calculating medication doses and IV flow rates Documenting the client’s response to basic life support (BLS) measures Handling medical emergencies Identifying client allergies and sensitivities Identifying the adverse effects of and contraindications to medication or IV therapy Implementing priority nursing actions in an emergency or disaster Initiating nursing interventions when surgical complications arise Managing and providing care to clients with infectious diseases Monitoring for alterations in body systems Monitoring for surgical complications Monitoring for wound infection Preparing for diagnostic tests to confirm accurate place- ment of a tube Preventing the complications of immobility Promoting an environment that will allow the client to express concerns Providing comfort and assistance to the client Providing nutrition and oral intake Providing interventions compatible with the client’s age; cultural, religious, spiritual and health care beliefs; education level; and language Providing personal hygiene as needed Recognizing changes in the client’s condition that indi- cate a potential complication and intervening appropriately Using assistive devices to prevent injury Using special equipment 170 UNIT IV Fundamentals of Care F u n d a m e n t a l s
- 189. CH AP TER 15 Health and Physical Assessment of the Adult Client PRIORITYCONCEPTS Clinical Judgment; Health Promotion CRITICALTHINK ING W hat Should Y ou Do? The nurse is performing a cardiovascular assessment and notes the presence of a blowing, swishing sound over the carotid artery. What should the nurse do? Answer located on p. 188. I. Environment/Setting A. Establish a relationship and explain the procedure to the client. B. Ensure privacy and make the client feel comfortable (comfortable room temperature, sufficient lighting, remove distractions such as noise or objects, and avoid interruptions). C. Sit down for the interview (avoid barriers such as a desk), maintain an appropriate social distance, and maintain eye level. D. Use therapeutic communication techniques and open-ended questions to obtain information about the client’s symptoms and concerns; allow time for the client to ask questions. E. Consider religious and cultural characteristics such as language (the need for an interpreter), values and beliefs, health practices, eye contact, and touch. F. Keep note-taking to a minimum so the client is the focus of attention. G. Types of health and physical assessments (Box 15-1) II. Health History A. General state of health: Body features and physical characteristics, body movements, body posture, level of consciousness, nutritional status, speech B. Chief complaint and history of present illness (doc- ument direct client quotes) that leads the client to seek care C. Family history: The health status of direct blood rel- atives as well as the client’s spouse D. Social history 1. Data about the client’s lifestyle, with a focus on factors that may affect health 2. Information about alcohol, drug, and tobacco use; sexual practices; tattoos; body piercing; travel history; and work setting to identify occu- pational hazards E. Domestic violence screening 1. Done to determine whether the client is experiencing any form of domestic violence 2. Conducted during a 1-to-1 interview with the client while obtaining the health history III. Mental Status Exam A. The mental status can be assessed while obtaining subjective data from the client during the health his- tory interview. B. Appearance 1. Note appearance, including posture, body move- ments, dress, and hygiene and grooming. 2. An inappropriate appearance and poor hygiene may be indicative of depression, manic disorder, dementia, organic brain disease, or another disorder. C. Behavior 1. Level of consciousness: Assess alertness and awareness and the client’s ability to interact appropriately with the environment. 2. Facial expression and body language: Check for appropriate eye contact and determine whether facial expression and body language are appro- priate to the situation; this assessment also pro- vides information regarding the client’s mood and affect. 3. Speech: Assess speech pattern for articulation and appropriateness of conversation. D. Cognitive level of functioning (Box 15-2) F u n d a m e n t a l s 171
- 190. IV. Physical Exam A. Overview 1. Gather equipment needed for the examination. 2. Use the senses of sight, smell, touch, and hearing to collect data. 3. Assessment includes inspection, palpation, per- cussion, and auscultation; these skills are per- formed one at a time, in this order (except the abdominal assessment). B. Assessment techniques 1. Inspection a. The first assessment technique, which uses vision and smell senses while observing the client b. Requires good lighting, adequate body exposure, and possibly the use of certain instruments such as an otoscope or ophthal- moscope 2. Palpation a. Uses the sense of touch; warm the hands before touching the client. b. Identify tender areas and palpate them last. c. Start with light palpation to detect surface characteristics, and then perform deeper palpation. d. Light palpation is done with 1 hand by pressing the skin gentlywith the tipsof2 or 3 fingersheld closetogether;deep palpation isdonebyplacing 1 hand on top of the other and pressing down with the fingertips of both hands. e. Assess texture, temperature, and moisture of the skin, as well as organ location and size and symmetry if appropriate. f. Assess for swelling, vibration or pulsation, rigidity or spasticity, and crepitation. g. Assess for the presence of lumps or masses, as well as the presence of tenderness or pain. 3. Percussion a. Involves tapping the client’s skin to assess underlying structures and to determine the presence of vibrations and sounds and, if pre- sent, their intensity, duration, pitch, quality, and location b. Provides information related to the presence of air, fluid, or solid masses as well as organ size, shape, and position c. Descriptions of findings include resonance, hyperresonance, tympany, dullness, or flatness 4. Auscultation: Involves listening to sounds pro- duced by the body for presence and quality, such as heart, lung, or bowel sounds C. Vital signs 1. Includes temperature, radial pulse (apical pulse may be measured during the cardiovascular assessment), respirations, blood pressure, pulse oximetry, and presence of pain (refer to Chapter 10 for information on vital signs, pulse oximetry, and pain) 2. Height, weight, and nutritional status are also assessed. V. Body Systems Assessment A. Integumentary system: Involves inspection and pal- pation of skin, hair, and nails. 1. Subjective data: Self-care behaviors, history of skin disease, medications being taken, environ- mental or occupational hazards and exposure to toxic substances, changes in skin color or pig- mentation, change in a mole or a sore that does not heal 2. Objective data: Color, temperature (hypothermia or hyperthermia); excessive dryness or moisture; skin turgor; texture (smoothness, firmness); excessive bruising, itching, rash; hair loss (alope- cia) or nail abnormalities such as pitting; lesions (may be inspected with a magnifier and light or with the use of a Wood’s light [ultraviolet light F u n d a m e n t a l s BOX 15-1 Types of Health and Physical Assessments Complete Assessment: Includes a complete health historyand physical examination and forms a baseline database. Focused Assessment: Focuses on a limited or short-term prob- lem, such as the client’s complaint. Episodic/Follow-up Assessment: Focuses on evaluating a cli- ent’s progress. Emergency Assessment: Involves the rapid collection of data, often during the provision of life-saving measures. BOX 15-2 The Mental Status Examination: Cognitive Level of Functioning Orientation: Assess client’s orientation to person, place, and time. Attention Span: Assess client’s ability to concentrate. Recent Memory: Assessed by asking the client to recall a recent occurrence (e.g., the means of transportation used to get to the health care agency for the physical assessment). Remote Memory: Assessed by asking the client about a verifi- able past event (e.g., a vacation). NewLearning: Used to assess the client’s abilityto recall unre- lated words identified by the nurse; the nurse selects 4 words and asks the client to recall the words 5, 10, and 30 minutes later. Judgment: Determine whether the client’s actions or decisions regarding discussions during the interview are realistic. Thought Processes and Perceptions: The way the client thinks and what the client says should be logical, coherent, and relevant; the client should be consistently aware of reality. 172 UNIT IV Fundamentals of Care
- 191. used in a darkened room]); scars or birthmarks; edema; capillary filling time (Boxes 15-3 and 15-4; Table 15-1) 3. Dark-skinned client a. Cyanosis: Check lips and tongue for a gray color; nail beds, palms, and soles for a blue color; and conjunctivae for pallor. b. Jaundice: Check oral mucous membranes for a yellow color; check the sclera nearest to the iris for a yellow color. c. Bleeding: Look for skin swelling and darken- ing and compare the affected side with the unaffected side. d. Inflammation: Check for warmth or a shiny or taut and pitting skin area, and compare with the unaffected side. 4. Refer to Chapter 46 for diagnostic tests related to the integumentary system To test skin turgor, pinch a large fold of skin and assess the ability of the skin to return to its place when released. Poor turgor occurs in severe dehydration or extreme weight loss. 5. Client teaching a. Provide information about factors that can be harmful to the skin, such as sun exposure. b. Encourage performing self-examination of the skin monthly. B. Head, neck, and lymph nodes: Involves inspection and palpation of the head, neck, and lymph nodes 1. Ask the client about headaches; episodes of diz- ziness (lightheadedness) or vertigo (spinning sensation); history of head injury; loss of con- sciousness; seizures; episodes of neck pain; limi- tations of range of motion; numbness or tingling in the shoulders, arms, or hands; lumps or swell- ing in the neck; difficulty swallowing; medica- tions being taken; and history of surgery in the head and neck region. 2. Head a. Inspect and palpate: Size, shape, masses or tenderness, and symmetry of the skull b. Palpate temporal arteries, located above the cheekbone between the eye and the top of the ear. c. Temporomandibular joint: Ask the client to open his or her mouth; note any crepitation, tenderness, or limited range of motion. d. Face: Inspect facial structures for shape, sym- metry, involuntary movements, or swelling, such as periorbital edema (swelling around the eyes). 3. Neck a. Inspect for symmetry of accessory neck muscles. b. Assess range of motion. c. Test cranial nerve XI (spinal accessory nerve) to assess muscle strength: Ask the client to push against resistance applied to the side of the chin (tests sternocleidomastoid mus- cle); also ask the client to shrug the shoulders against resistance (tests trapezius muscle). d. Palpate the trachea: It should be midline, without any deviations. e. Thyroid gland: Inspect the neck as the client takes a sip of water and swallows (thyroid tissue moves up with a swallow); palpate using an anterior-posterior approach F u n d a m e n t a l s TABLE 15-1 Pitting Edema Scale Scale Description “Measurement”* 1+ A barely perceptible pit 2 mm (3 =32 in) 2+ 4 mm 1+ 2 mm 3+ 6 mm 4+ 8 mm 2+ A deeper pit, rebounds in a few seconds 4 mm (6 32 in) 3+ A deep pit, rebounds in 10-20 sec 6 mm (1 =4 in) 4+ A deeper pit, rebounds in > 30 sec 8 mm (5 =16 in) *“Measurement” is in quotation marks because depth of edema is rarely actually measured but is included as a frame of reference. Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 2013, Mosby. Description column data from Kirton C: Assessing edema, Nursing 96 26(7):54, 1996. BOX 15-4 Assessing Capillary Filling Time 1. Depress the nail bed to produce blanching. 2. Release and observe for the return of color. 3. Color will return within 3 seconds if arterial capillary perfu- sion is normal. BOX 15-3 Characteristics of Skin Color Cyanosis: Mottled bluish coloration Erythema: Redness Pallor: Pale, whitish coloration Jaundice: Yellow coloration 173 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 192. (usually the normal adult thyroid cannot be palpated); if it is enlarged, auscultate for a bruit. 4. Lymph nodes a. Palpate using a gentle pressure and a circular motion of the finger pads. b. Begin with the preauricular lymph nodes (in front of the ear); move to the posterior auric- ular lymph nodes and then downward toward the supraclavicular lymph nodes. c. Palpate with both hands, comparing the 2 sides for symmetry. d. If nodes are palpated, note their size, shape, location, mobility, consistency, and tenderness. 5. Client teaching: Instruct the client to notify the health care provider (HCP) if persistent head- ache, dizziness, or neck pain occurs; if swelling or lumps are noted in the head and neck region; or if a neck or head injury occurs. Neck movements are never performed if the client has sustained a neck injury or if a neck injury is suspected. C. Eyes: Includes inspection, palpation, vision-testing procedures, and the use of an ophthalmoscope 1. Subjective data: Difficulty with vision (e.g., decreased acuity, double vision, blurring, blind spots); pain, redness, swelling, watery or other discharge from the eye; use of glasses or contact lenses; medications being taken; history of eye problems 2. Objective data a. Inspect the external eye structures, including eyebrows, for symmetry; eyelashes for even distribution; eyelids for ptosis (drooping); eyeballs for exophthalmos (protrusion) or enophthalmos (recession into the orbit; sunken eye). b. Inspect the conjunctiva (should be clear), sclera (should be white), and lacrimal appara- tus (check for excessive tearing, redness, ten- derness, or swelling); cornea and lens (should be smooth and clear); iris (should be flat, with a round regular shape and even coloration); eyelids; and pupils 3. Snellen eye chart a. The Snellen eye chart is a simple tool used to measure distance vision. b. Position the client in a well-lit spot 20 feet (6 meters) from the chart, with the chart at eye level, and ask the client to read the smallest line that he or she can discern. c. Instruct the client to leave on glasses or leave in contact lenses; if the glasses are for reading only, they are removed because they blur dis- tance vision. d. Test 1 eye at a time. e. Record the result using the fraction at the end of the last line successfully read on the chart. f. Normal visual acuity is 20/20 (distance in feet at which the client is standing from the chart/ distance in feet at which a normal eye could have read that particular line). 4. Near vision a. Use a hand-held vision screener (held about 14 inches [35.5 centimeters] from the eye) that contains various sizes of print or ask the client to read from a magazine. b. Test each eye separately with the client’s glasses on or contact lenses in. c. Normal result is 14/14 (distance in inches at which the subject holds the card from the eye/distance in inches at which a normal eye could have read that particular line). 5. Confrontation test a. Acrude but rapid test used to measure periph- eral vision and compare the client’s periph- eral vision with the nurse’s (assuming that the nurse’s peripheral vision is normal) b. The client covers 1 eye and looks straight ahead; the nurse, positioned 2 feet away (60 centimeters), covers his or her eye opposite the client’s covered eye. c. The nurse advances a finger or other small object from the periphery from several direc- tions; the client should see the object at the same time the nurse does. 6. Corneal light reflex a. Used to assess for parallel alignment of the axes of the eyes b. Client is asked to gaze straight ahead as the nurse holds a light about 12 inches (30 centi- meters) from the client. c. The nurse looks for reflection ofthe light on the corneas in exactly the same spot in each eye. 7. Cover test a. Used to check for slight degrees of deviated alignment b. Each eye is tested separately. c. The nurse asks the client to gaze straight ahead and cover 1 eye. d. The nurse examines the uncovered eye, expecting to note a steady, fixed gaze. 8. Extraocular muscle function (6 cardinal posi- tions of gaze) (Fig. 15-1) a. The 6 muscles that attach the eyeball to its orbit and serve to direct the eye to points of interest are tested. b. Client holds head still and is asked to move his or her eyes and follow a small object. c. The examiner notes any parallel movements of the eye or nystagmus, an involuntary, rhythmic, rapid twitching of the eyeballs. F u n d a m e n t a l s 174 UNIT IV Fundamentals of Care
- 193. 9. Color vision a. Tests for color vision involve picking num- bers or letters out of a complex and colorful picture. b. The Ishihara chart is used for testing and con- sists of numbers composed of colored dots located within a circle of colored dots. c. The client is asked to read the numbers on the chart. d. Each eye is tested separately. e. Reading the numbers correctly indicates nor- mal color vision. f. The test is sensitive for the diagnosis of red- green blindness but cannot detect discrimina- tion of blue. The first slide on the Ishihara chart is one that every- one can discriminate; failure to identifynumbers on this slide suggests a problem with performing the test, not a problem with color vision. 10. Pupils (Box 15-5) a. The pupils are round and of equal size. b. Increasing light causes pupillary constriction. c. Decreasing light causes pupillary dilation. d. Constriction of both pupils is a normal response to direct light. 11. Sclera and cornea a. Normal sclera color is white. b. Ayellow color to the sclera may indicate jaun- dice or systemic problems. c. In a dark-skinned person, the sclera may nor- mally appear yellow; pigmented dots may be present. d. The cornea is transparent, smooth, shiny, and bright. e. Cloudy areas or specks on the cornea may be the result of an accident or eye injury. 12. Ophthalmoscopy a. The ophthalmoscope is an instrument used to examine the external structures and the inte- rior of the eye. b. The room is darkened so that the pupil will dilate. c. The instrument is held with the right hand when examining the right eye and with the left hand when examining the left eye. d. The client is asked to look straight ahead at an object on the wall. e. The examiner should approach the client’s eye from about 12 to 15 inches (30.5 to 38 centimeters) away and 15 degrees lateral to the client’s line of vision. f. As the instrument is directed at the pupil, a red glare (red reflex) is seen in the pupil. g. The red reflex is the reflection of light on the vascular retina. h. Absence of the red reflex may indicate opacity of the lens. i. The retina, optic disc, optic vessels, fundus, and macula can be examined. 13. Refer to Chapter 60 for diagnostic tests related to the eye. 14. Client teaching a. Instruct the client to notify the HCP if alterations in vision occur or any red- ness, swelling, or drainage from the eye is noted. b. Inform the client of the importance of regular eye examinations. D. Ears: Includes inspection, palpation, hearing tests, vestibular assessment, and the use of an otoscope 1. Subjective data: Difficulty hearing, earaches, drainage from the ears, dizziness, ringing in the ears, exposure to environmental noise, use of a hearing aid, medications being taken, history of ear problems or infections 2. Objective data a. Inspect and palpate the external ear, noting size, shape, symmetry, skin color, and the presence of pain. F u n d a m e n t a l s BOX 15-5 Assessing and Documenting Pupillary Responses Pupillary Light Reflex 1. Darken the room (to dilate the client’s pupils) and ask the client to look forward. 2. Test each eye. 3. Advance a light in from the side to note constriction of the same-side pupil (direct light reflex) and simultaneous con- striction of the other pupil (consensual light reflex). Accommodation 1. Ask the client to focus on a distant object (dilates the pupil). 2. Ask the client to shift gaze to a near object held about 3 inches (7.5 centimeters) from the nose. 3. Normal response includes pupillary constriction and convergence of the axes of the eyes. Documenting Normal Findings: PERRLA P¼pupils E¼equal R¼round RL¼reactive to light A¼reactive to accommodation III III III III VI IV III III VI FIGURE 15-1 Checking extraocular muscles in the 6 cardinal positions. This indicates the functioning of cranial nerves III, IV, and VI. 175 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 194. F u n d a m e n t a l s b. Inspect the external auditory meatus for size, swelling, redness, discharge, and foreign bod- ies; some cerumen (earwax) may be present. 3. Auditory assessment a. Sound is transmitted by air conduction and bone conduction. b. Air conduction takes 2 or 3 times longer than bone conduction. c. Hearing loss is categorized as conductive, sen- sorineural, or mixed conductive and sensorineural. d. Conductive hearing loss is caused by any physical obstruction to the transmission of sound waves. e. Sensorineural hearing loss is caused by a defect in the cochlea, eighth cranial nerve, or the brain itself. f. A mixed hearing loss is a combination of a conductive and sensorineural hearing loss; it results from problems in both the inner ear and the outer ear or middle ear. 4. Voice (Whisper) test a. Used to determine whether hearing loss has occurred b. One ear is tested at a time (the ear not being tested is occluded by the client). c. The nurse stands 1 to 2 feet (30 to 60 centime- ters) from the client, covers his or her mouth so that the client cannot read the lips, exhales fully, and softly whispers 2-syllable words in the direction of the unoccluded ear; the client points a finger up during the test when the nurse’s voice is heard (a ticking watch may also be used to test hearing acuity). d. Failure to hear the sounds could indicate pos- sible fluid collection and/or consolidation, requiring further assessment. 5. Watch test a. A ticking watch is used to test for high- frequency sounds. b. The examiner holds a ticking watch about 5 inches (12.5 centimeters) from each ear and asks the client if the ticking is heard. 6. Tuning fork tests a. Used to measure hearing on the basis of air conduction or bone conduction; includes the Weber and Rinne tests b. To activate the tuningfork, the nurse holds the base and lightlytaps the tines against the other hand, setting the fork in vibration. 7. Weber test a. Determines whether the client has a conduc- tive or sensorineural hearing loss b. Stem of the vibrating tuning fork is placed in the midline of the client’s skull and the client is asked if the tone sounds the same in both ears or better in 1 ear. c. The client hears the tone by bone conduction and the sound should be heard equally in both ears. d. In conductive loss, the sound travels toward the impaired ear. e. In sensorineural loss, the sound travels toward the good ear. 8. Rinne test a. Stem of the vibrating tuning fork is placed on the client’s mastoid process. b. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should still hear a sound. c. Normally the sound is heard twice as long by way of air conduction (AC) (near the ear canal) than by way of bone conduction (BC) (at the mastoid process); AC> BC. d. In sensorineural hearing loss, air conduction is heard longer than bone conduction, but it is not heard to be twice as long. e. In conductive hearing loss, the bone conduc- tion sound is longer than or equal to the air conduction sound. 9. Vestibular assessment (Box 15-6) 10. Otoscopic exam Before performing an otoscopic exam and inserting the speculum, check the auditory canal for foreign bod- ies. Instruct the client not to move the head during the examination to avoid damage to the canal and tympanic membrane. a. The client’s head is tilted slightly away and the otoscope is held upside down as if it were a large pen; this permits the examiner’s hand to lay against the client’s head for support. b. In an adult, pull the pinna up and back to straighten the external canal. c. Visualize the external canal while slowly inserting the speculum. d. The normal external canal is pink and intact, without lesions and with varying amounts of cerumen and fine little hairs. e. Assess the tympanic membrane for intactness; the normal tympanic membrane is intact, without perforations, and should be free from lesions. f. The tympanic membrane is transparent, o- paque, pearly gray, and slightly concave. g. A fluid line or the presence of air bubbles is not normally visible. h. If the tympanic membrane is bulging or retracting, the edges of the light reflex will be fuzzy (diffuse) and may spread over the tympanic membrane. 176 UNIT IV Fundamentals of Care
- 195. F u n d a m e n t a l s The otoscope is never introduced blindly into the external canal because of the risk of perforating the tym- panic membrane. 11. Refer to Chapter 60 for diagnostic tests related to the ear. 12. Client teaching a. Instruct the client to notify the HCP if an alteration in hearing or ear pain or ringing in the ears occurs, or if redness, swelling, or drainage from the ear is noted. b. Instruct the client in the proper method of cleaning the ear canal. c. The client should cleanse the ear canal with the corner of a moistened washcloth and should never insert sharp objects or cotton-tipped applicators into the ear canal. E. Nose, mouth, and throat: Includes inspection and palpation 1. Subjective data a. Nose: Ask about discharge or nosebleed (epi- staxis), facial or sinus pain, history of fre- quent colds, altered sense of smell, allergies, medications being taken, history of nose trauma or surgery. b. Mouth and throat: Ask about the presence of sores or lesions; bleeding from the gums or elsewhere; altered sense of taste; toothaches; use of dentures or other appliances; tooth and mouth care hygiene habits; at-risk behav- iors (e.g., smoking, alcohol consumption); and history of infection, trauma, or surgery. 2. Objective data a. External nose should be midline and in pro- portion to other facial features. b. Patency of the nostrils can be tested by push- ing each nasal cavity closed and asking the cli- ent to sniff inward through the other nostril. c. Anasal speculum and penlight or a short, wide- tipped speculum attached to an otoscope head is used to inspect for redness, swelling, dis- charge, bleeding, or foreign bodies; the nasal septum is assessed for deviation. d. The nurse presses the frontal sinuses (located below the eyebrows) and over the maxillary sinuses (located below the cheek- bones); the client should feel firm pressure but no pain. e. The external and inner surfaces of the lips are assessed for color, moisture, cracking, or lesions. f. The teeth are inspected for condition and number (should be white, spaced evenly, straight, and clean, free of debris and decay). g. The alignment of the upper and lower jaw is assessed by having the client bite down. h. The gums are inspected for swelling, bleed- ing, discoloration, and retraction of gingival margins (gums normally appear pink). i. The tongue is inspected for color, surface characteristics, moisture, white patches, nod- ules, and ulcerations (dorsal surface is nor- mally rough; ventral surface is smooth and glistening, with visible veins). j. The nurse retracts the cheek with a tongue depressor to check the buccal mucosa for color and the presence of nodules or lesions; normal mucosa is glistening, pink, soft, moist, and smooth. k. Using a penlight and tongue depressor, the nurse inspects the hard and soft palates for color, shape, texture, and defects; the hard palate (roof of the mouth), which is located anteriorly, should be white and dome- shaped, and the soft palate, which extends posteriorly, should be light pink and smooth. BOX 15-6 Vestibular Assessment Test for Falling 1. The examiner asks the client to stand with the feet together, arms hanging loosely at the sides, and eyes closed. 2. The client normallyremains erect, with onlyslight swaying. 3. A significant sway is a positive Romberg sign. Test for Past Pointing 1. The client sits in front of the examiner. 2. The client closes the eyes and extends the arms in front, pointing both index fingers at the examiner. 3. The examiner holds and touches his or her own extended index fingers under the client’s extended index fingers to give the client a point of reference. 4. The client is instructed to raise both arms and then lower them, attempting to return to the examiner’s extended index fingers. 5. The normal test response is that the client can easilyreturn to the point of reference. 6. The client with a vestibular function problem lacks a nor- mal sense of position and cannot return the extended fin- gers to the point ofreference; instead, the fingers deviate to the right or left of the reference point. Gaze Nystagmus Evaluation 1. The client’s eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and downward. 2. Any spontaneous nystagmus— an involuntary, rhythmic, rapid twitching of the eyeballs— represents a problem with the vestibular system. Dix-Hallpike Maneuver 1. The client starts in a sitting position; the examiner lowers the client to the exam table and rather quicklyturns the cli- ent’s head to the 45-degree position. 2. If after about 30 seconds there is no nystagmus, the client is returned to a sitting position and the test is repeated on the other side. 177 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 196. l. The uvula is inspected for midline location; the nurse asks the client to say “ahhh” and watches for the soft palate and uvula to rise in the midline (this tests 1 function of cranial nerve X, the vagus nerve). m. Using a penlight and tongue depressor, the nurse inspects the throat for color, presence of tonsils, and the presence of exudate or lesions; 1 technique to test cranial nerve XII (the hypoglossal nerve) is asking the client to stick out the tongue (should protrude in the midline). n. To test the gag reflex, touch the posterior pharynx with the end of a tongue blade; the client should gag momentarily (this tests the function of cranial nerve IX, the glossopharyngeal nerve). 3. Client teaching a. Emphasize the importance of hygiene and tooth care, as well as regular dental examina- tions and the use of fluoridated water or fluo- ride supplements. b. Encourage the client to avoid at-risk behav- iors (e.g., smoking, alcohol consumption). c. Stress the importance of reporting pain or abnormal occurrence (e.g., nodules, lesions, signs of infection). F. Lungs 1. Subjective data: Cough; expectoration of spu- tum; shortness of breath or dyspnea; chest pain on breathing; smoking history; environ- mental exposure to pollution or chemicals; medications being taken; history of respiratory disease or infection; last tuberculosis test, chest radiograph, pneumonia, and any influ- enza immunizations. Record the smoking his- tory in pack-years (the number of packs per day times the number of years smoked). For example, a client who has smoked one-half pack a day for 20 years has a 10–pack-year smoking history. 2. Objective data: Includes inspection, palpation, percussion, and auscultation 3. Inspection of the anterior and posterior chest: Note skin color and condition and the rate and quality of respirations, look for lumps or lesions, note the shape and configuration of the chest wall, and note the position the client takes to breathe. 4. Palpation: Palpate the entire chest wall, noting skin temperature and moisture and looking for areas of tenderness and lumps, lesions, or masses; assess chest excursion and tactile or vocal fremitus (Box 15-7). 5. Percussion a. Starting at the apices, percuss across the top of the shoulders, moving to the interspaces, making a side-to-side comparison all the way down the lung area (Fig. 15-2). b. Determine the predominant note; resonance is noted in healthy lung tissue. c. Hyperresonance is noted when excessive air is present and a dull note indicates lung density. 6. Auscultation a. Using the flat diaphragm endpiece of the stethoscope, hold it firmly against the chest wall, and listen to at least 1 full respiration in each location (anterior, posterior, and lateral). b. Posterior: Start at the apices and move side to side for comparison (see Fig. 15-2). c. Anterior: Auscultate the lung fields from the apices in the supraclavicular area down to the 6th rib; avoid percussion and auscultation over female breast tissue (displace this tissue) because a dull sound will be produced (see Fig. 15-2). d. Compare findings on each side. 7. Normal breath sounds: Three types of breath sounds are considered normal in certain parts of the thorax, including vesicular, bronchovesicular, and bronchial; breath sounds should be clear to auscultation (Fig. 15-3). 8. Abnormal breath sounds: Also known as adven- titious sounds (Table 15-2) 9. Voice sounds (Box 15-8) a. Performed when a pathological lung condi- tion is suspected F u n d a m e n t a l s BOX 15-7 Palpation of the Chest Chest Excursion Posterior: The nurse places the thumbs along the spinal pro- cesses at the 10th rib, with the palms in light contact with the posterolateral surfaces. The nurse’s thumbs should be about 2 inches (5 centimeters) apart, pointing toward the spine, with the fingers pointing laterally. Anterior: The nurse places the hands on the anterolateral wall with the thumbs along the costal margins, pointing toward the xiphoid process. The nurse instructs the client to take a deep breath after exhaling. The nurse should note movement of the thumbs and chest excursion should be symmetrical, separating the thumbs approximately 2 inches (5 centimeters). Tactile or Vocal Fremitus The nurse places the ball or lower palm of the hand over the chest, starting at the lung apices and palpating from side to side. The nurse asks the client to repeat the words “ninety-nine.” Symmetrical palpable vibration should be felt by the nurse. 178 UNIT IV Fundamentals of Care
- 197. F u n d a m e n t a l s 1 4 5 8 7 6 3 4 5 8 9 7 10 6 3 2 1 2 1 4 5 7 6 3 2 C A B FIGURE 15-2 Landmarks for chest auscultation and percussion. A, Posterior view. B, Anterior view. C, Lateral views. Bronchovesicular over main bronchi Key: Vesicular over lesser bronchi, bronchioles, and lobes Bronchial over trachea A B FIGURE 15-3 Auscultatory sounds. A, Anterior thorax. B, Posterior thorax. 179 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 198. b. Auscultate over the chest wall; the client is asked to vocalize words or a phrase while the nurse listens to the chest. c. Normal voice transmission is soft and muffled; the nurse can hear the sound but is unable to distinguish exactly what is being said. When auscultating breath sounds, instruct the cli- ent to breathe through the mouth and monitor the client for dizziness. 10. Refer to Chapter 54 for diagnostic tests related to the respiratory system. 11. Client teaching a. Encourage the client to avoid exposure to environmental hazards, including smoking (discuss smoking cessation programs as appropriate). b. Client should undergo periodic examinations as prescribed (e.g., chest x-raystudy, tuberculo- sis skin testing; refer to Chapter 54). c. Encourage the client to obtain pneumonia and influenza immunizations. d. HCP should be notified if client experiences persistent cough, shortness of breath, or other respiratory symptoms. G. Heart and peripheral vascular system 1. Subjective data: Chest pain, dyspnea, cough, fatigue, edema, nocturia, leg pain or cramps (claudication), changes in skin color, obesity, medications being taken, cardiovascular risk fac- tors, family history of cardiac or vascular prob- lems, personal history of cardiac or vascular problems 2. Objective data: May include inspection, palpa- tion, percussion, and auscultation 3. Inspection: Inspect the anterior chest for pulsa- tions (apical impulse) created as the left ventricle rotates against the chest wall during systole; not always visible. 4. Palpation a. Palpate the apical impulse at the fourth or fifth interspace, or medial to the midclavicu- lar line (not palpable in obese clients or cli- ents with thick chest walls). b. Palpate the apex, left sternal border, and base for pulsations; normally none are present. F u n d a m e n t a l s TABLE 15-2 Characteristics of Adventitious Sounds Adventitious Sound Characteristics Clinical Examples Crackles (previously called rales) Fine crackles High-pitched crackling and popping noises (discontinuous sounds) heard during the end of inspiration. Not cleared by cough Maybe heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases Medium crackles Medium-pitched, moist sound heard about halfway through inspiration. Not cleared by cough Same as above, but condition is worse Coarse crackles Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration Same as above, but condition is worse or may be heard in terminally ill clients with diminished gag reflex. Also heard in pulmonary edema and pulmonary fibrosis Wheeze (also called sibilant wheeze) High-pitched, musical sound similar to a squeak. Heard more commonly during expiration, but may also be heard during inspiration. Occurs in small airways Heard in narrowed airway diseases such as asthma Rhonchi (also called sonorous wheeze) Low-pitched, coarse, loud, low snoring or moaning tone. Actuallysounds like snoring. Heard primarily during expiration, but may also be heard during inspiration. Coughing may clear Heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis Pleural friction rub Asuperficial, low-pitched, coarse rubbing or grating sound. Sounds like 2 surfaces rubbing together. Heard throughout inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough Heard in individuals with pleurisy (inflammation of the pleural surfaces) Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 2013, Mosby. BOX 15-8 Voice Sounds Bronchophony 1. Ask the client to repeat the words “ninety-nine.” 2. Normal voice transmission is soft, muffled, and indistinct. Egophony 1. Ask the client to repeat a long “ee-ee-ee” sound. 2. Normally the nurse would hear the “ee-ee-ee” sound. Whispered Pectoriloquy 1. Ask the client to whisper the word “ninety-nine.” 2. Normal voice transmission is faint, muffled, and almost inaudible. 180 UNIT IV Fundamentals of Care
- 199. F u n d a m e n t a l s 5. Percussion: May be performed to outline the heart’s borders and to check for cardiac enlarge- ment (denoted by resonance over the lung and dull notes over the heart). 6. Auscultation a. Areas of the heart (Fig. 15-4) b. Auscultate heart rate and rhythm; check for a pulse deficit (auscultate the apical heartbeat while palpating an artery) if an irregularity is noted. c. Assess S1 (“lub”) and S2 (“dub”) sounds, and listen for extra heart sounds, as well as the presence of murmurs (blowing or swooshing noise that can be faint or loud with a high, medium, or low pitch). 7. Peripheral vascular system a. Assess adequacy of blood flow to the extrem- ities by palpating arterial pulses for equality and symmetry and checking the condition of the skin and nails. b. Check for pretibial edema and measure calf circumference (see Table 15-1). c. Measure blood pressure. d. Palpate superficial inguinal nodes (using firm but gentle pressure), beginning in the ingui- nal area and moving down toward the inner thigh. e. An ultrasonic stethoscope may be needed to amplify the sounds of a pulse wave if the pulse cannot be palpated. f. Carotid artery: Located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle g. Palpate 1 carotid artery at a time to avoid compromising blood flow to the brain. h. Auscultate each carotid artery for the presence of a bruit (a blowing, swishing, or buzzing, humming sound), which indicates blood flow turbulence; normally a bruit is not present. i. Palpate the arteries in the extremities (Box 15-9). 8. Refer to Chapter 56 for diagnostic tests related to the cardiovascular system. 9. Client teaching a. Advise client to modify lifestyle for risk factors associated with heart and vascular disease. b. Encourage the client to seek regular physical examinations. c. Client should seek medical assistance for signs of heart or vascular disease. H. Breasts 1. Subjective data: Pain or tenderness, lumps or thickening, swollen axillary lymph nodes, nipple discharge, rash or swelling, medications being taken, personal or family history of breast dis- ease, trauma or injury to the breasts, previous surgery on the breasts, breast self-examination (BSE) compliance, mammograms as prescribed 2. Objective data: Inspection and palpation 3. Inspection a. Performed with the client’s arms raised above the head, the hands pressed against the hips, and the arms extended straight ahead while the client sits and leans forward b. Assess size and symmetry (1 breast is often larger than the other); masses, flattening, Base A P E T M Apex 2nd RICS (aortic) 2nd LICS (pulmonic) 3rd LICS (Erb’s point) 4th LICS (tricuspid) 5th LMCL (mitral) FIGURE 15-4 Auscultation areas of the heart. LICS, Left intercostal space; LMCL, left midclavicular line; RICS, right intercostal space. BOX 15-9 Arterial Pulse Points and Grading the Force of Pulses Arteries in the Arms and Hands Radial Pulse: Located at the radial side of the forearm at the wrist Ulnar Pulse: Located on the opposite side ofthe location ofthe radial pulse at the wrist Brachial Pulse: Located above the elbow at the antecubital fossa, between the biceps and triceps muscles Arteries in the Legs Femoral Pulse: Located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine Popliteal Pulse: Located behind the knee Dorsalis Pedis Pulse: Located at the top of the foot, in line with the groove between the extensor tendons of the great and first toes Posterior Tibial Pulse: Located on the inside of the ankle, behind and below the medial malleolus (ankle bone) Grading the Force 4+¼Strong and bounding 3+¼Full pulse, increased 2+¼Normal, easily palpable 1+¼Weak, barely palpable 181 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 200. retraction, or dimpling; color and venous pat- tern; size, color, shape, and discharge in the nipple and areola; and the direction in which nipples point. 4. Palpation a. Client lies supine, with the arm on the side being examined behind the head and a small pillow under the shoulder. b. The nurse uses the pads of the first 3 fingers to compress the breast tissue gently against the chest wall, noting tissue consistency. c. Palpation is performed systematically, ensur- ing that the entire breast and tail are palpated. d. The nurse notes the consistency of the breast tissue, which normally feels dense, firm, and elastic. e. The nurse gently palpates the nipple and are- ola and compresses the nipple, noting any discharge. 5. Axillary lymph nodes a. The nurse faces the client and stands on the side being examined, supporting the client’s arm in a slightly flexed position, and abducts the arm away from the chest wall. b. The nurse places the free hand against the cli- ent’s chest wall and high in the axillary hol- low, then, with the fingertips, gently presses down, rolling soft tissue over the surface of the ribs and muscles. c. Lymph nodes are normally not palpable. 6. Client teaching a. Encourage and teach the client to perform BSE (refer to Chapter 48 for information on performing BSE). b. Client should report lumps or masses to the HCP immediately. c. Regular physical examinations and mammo- grams should be obtained as prescribed. I. Abdomen 1. Subjective data: Changes in appetite or weight, difficulty swallowing, dietary intake, intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications currently being taken, his- tory of abdominal problems or abdominal surgery 2. Objective data a. Ask the client to empty the bladder. b. Be sure to warm the hands and the endpiece of the stethoscope. c. Examine painful areas last. When performing an abdominal assessment, the specific order for assessment techniques is inspection, auscultation, percussion, and palpation. 3. Inspection a. Contour: Look down at the abdomen and then across the abdomen from the rib margin to the pubic bone; describe as flat, rounded, concave, or protuberant. b. Symmetry: Note any bulging or masses. c. Umbilicus: Should be midline and inverted d. Skin surface: Should be smooth and even e. Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves may be noted across the abdomen. 4. Auscultation a. Performed before percussion and palpation, which can increase peristalsis. b. Hold the stethoscope lightly against the skin and listen for bowel sounds in all 4 quad- rants; begin in the right lower quadrant (bowel sounds are normally heard here). c. Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30 times a minute. d. Identify as normal, hypoactive, or hyperactive (borborygmus). e. Absent sounds: Auscultate for 5 minutes before determining that sounds are absent. f. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits. 5. Percussion a. All 4 quadrants are percussed lightly. b. Borders of the liver and spleen are percussed. c. Tympany should predominate over the abdo- men, with dullness over the liver and spleen. d. Percussion over the kidney at the 12th rib (costovertebral angle) should produce no pain. 6. Palpation a. Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about 1 cm; next perform deep palpation, depress- ing 5 to 8 cm. b. Palpate the liver and spleen (spleen may not be palpable). c. Palpate the aortic pulsation in the upper abdomen slightly to the left of midline; nor- mally it pulsates in a forward direction (pul- sation expands laterally if an aneurysm is present). 7. Refer to Chapter 52 for diagnostic tests related to the gastrointestinal system. 8. Client teaching a. Encourage the client to consume a balanced diet; obesity needs to be prevented. b. Substances that can cause gastric irritation should be avoided. c. The regular use of laxatives is discouraged. d. Lifestyle behaviors that can cause gastric irri- tation (e.g., spicy foods) should be modified. e. Regular physical examinations are important. F u n d a m e n t a l s 182 UNIT IV Fundamentals of Care
- 201. f. The client should report gastrointestinal problems to the HCP. J. Musculoskeletal system 1. Subjective data: Joint pain or stiffness; redness, swelling, or warm joints; limited motion of joints; muscle pain, cramps, or weakness; bone pain; limitations in activities of daily living; exercise patterns; exposure to occupational hazards (e.g., heavy lifting, prolonged standing or sitting); medications being taken; history of joint, muscle, or bone injuries; history of surgery of the joints, muscles, or bones 2. Objective data: Inspection and palpation 3. Inspection: Inspect gait and posture, and for cervical, thoracic, and lumbar curves (Box 15-10). 4. Palpation: Palpate all bones, joints, and surrounding muscles. 5. Range of motion a. Perform active and passive range-of-motion exercises of each major joint. b. Check for pain, limited mobility, spastic movement, joint instability, stiffness, and contractures. c. Normally joints are nontender, without swelling, and move freely. 6. Muscle tone and strength a. Assess duringmeasurement ofrange ofmotion. b. Ask client to flex the muscle to be examined and then to resist while applying opposing force against the flexion. c. Assess for increased tone (hypertonicity) or little tone (hypotonicity). 7. Grading muscle strength (Table 15-3) 8. Refer to Chapter 64 for diagnostic tests related to the musculoskeletal system. 9. Client teaching a. The client should consume a balanced diet, including foods containing calcium and vitamin D. b. Activities that cause muscle strain or stress to the joints should be avoided. c. Encourage the client to maintain a normal weight. d. Participation in a regular exercise program is beneficial. e. The client should contact the HCP if joint or muscle pain or problems occur or if limitations in range of motion or muscle strength develop. K. Neurological system 1. Subjective data: Headaches, dizziness or vertigo, tremors, weakness, incoordination, numbness or tingling in any area of the body, difficulty speak- ing or swallowing, medications being taken, his- tory of seizures, history of head injury or surgery, exposure to environmental or occupational haz- ards (e.g., chemicals, alcohol, drugs) 2. Objective data: Assessment of cranial nerves, level of consciousness, pupils, motor function, cerebellar function, coordination, sensory func- tion, and reflexes 3. Note mental and emotional status, behavior and appearance, language ability, and intellectual functioning, including memory, knowledge, abstract thinking, association, and judgment. 4. Vital signs: Check temperature, pulse, respira- tions, and blood pressure; monitor for blood pressure or pulse changes, which may indicate increased intracranial pressure (see Chapter 62 for abnormal respiratory patterns). 5. Cranial nerves (Table 15-4) 6. Level of consciousness a. Assess the client’s behavior to determine level of consciousness (e.g., alertness, confusion, delirium, unconsciousness, stupor, coma); assessment becomes increasingly invasive as the client is less responsive. b. Speak to client. c. Assess appropriateness of behavior and conversation. d. Lightly touch the client (as culturally appropriate). F u n d a m e n t a l s BOX 15-10 Common Postural Abnormalities Lordosis (Swayback): Increased lumbar curvature Kyphosis (Hunchback): Exaggeration of the posterior curva- ture of the thoracic spine Scoliosis: Lateral spinal curvature TABLE 15-3 Criteria for Grading and Recording Muscle Strength Functional Level Lovett Scale Grade Percentage of Normal No evidence of contractility Zero (0) 0 0 Evidence of slight contractility Trace (T) 1 10 Complete range of motion with gravity eliminated Poor (P) 2 25 Complete range of motion with gravity Fair (F) 3 50 Complete range of motion against gravity with some resistance Good (G) 4 75 Complete range of motion against gravity with full resistance Normal (N) 5 100 Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 2013, Mosby. 183 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 202. F u n d a m e n t a l s TABLE 15-4 Assessment of the Cranial Nerves Cranial Nerve Test Cranial Nerve I: Olfactory ▪ Sensory ▪ Controls the sense of smell ▪ Have the client close the eyes and occlude 1 nostril with a finger ▪ Ask the client to identify nonirritating and familiar odors (e.g., coffee, tea, cloves, soap, chewing gum, peppermint) ▪ Repeat the test on the other nostril Cranial Nerve II: Optic ▪ Sensory ▪ Controls vision ▪ Assess visual acuity with a Snellen chart and perform an ophthalmoscopic exam ▪ Check peripheral vision by confrontation ▪ Check color vision Cranial Nerves III, IV, and VI Cranial Nerve III: Oculomotor ▪ Motor ▪ Controls pupillary constriction, upper- eyelid elevation, and most eye movement ▪ The motor functions of cranial nerves III, IV, and VI overlap; therefore, they should be tested together ▪ Inspect the eyelids for ptosis (drooping); then assess ocular movements and note any eye deviation ▪ Test accommodation and direct and consensual light reflexes Cranial Nerve IV: Trochlear ▪ Motor ▪ Controls downward and inward eye movement Cranial Nerve VI: Abducens ▪ Motor ▪ Controls lateral eye movement Cranial Nerve V: Trigeminal ▪ Sensory and motor ▪ Controls sensation in the cornea, nasal and oral mucosa, and facial skin, as well as mastication ▪ To test motor function, ask the client to clench the teeth and assess the muscles of mastication; then try to open the client’s jaws after asking the client to keep them tightly closed ▪ The corneal reflex may be tested by the health care provider; this is done by lightly touching the client’s cornea with a cotton wisp (this test may be omitted if the client is alert and blinking normally) ▪ Check sensory function by asking the client to close the eyes; lightly touch forehead, cheeks, and chin, noting whether the touch is felt equally on the 2 sides Cranial Nerve VII: Facial ▪ Sensory and motor ▪ Controls movement of the face and taste sensation ▪ Test taste perception on the anterior two thirds of the tongue; the client should be able to taste salty and sweet tastes ▪ Have the client smile, frown, and show the teeth ▪ Ask the client to puff out the cheeks ▪ Attempt to close the client’s eyes against resistance Cranial Nerve VIII: Acoustic or Vestibulocochlear ▪ Sensory ▪ Controls hearing and vestibular function ▪ Assessing the client’s ability to hear tests the cochlear portion ▪ Assessing the client’s sense of equilibrium tests the vestibular portion ▪ Check the client’s hearing, using acuity tests ▪ Observe the client’s balance and watch for swaying when he or she is walking or standing ▪ Assessment of sensorineural hearing loss may be done with the Weber or Rinne test Cranial Nerves IX and X Cranial Nerve IX: Glossopharyngeal ▪ Sensory and motor ▪ Controls swallowing ability, sensation in the pharyngeal soft palate and tonsillar mucosa, taste perception on the posterior third of the tongue, and salivation ▪ Usually cranial nerves IX and Xare tested together ▪ Test taste perception on the posterior one third of the tongue or pharynx; the client should be able to taste bitter and sour tastes ▪ Inspect the soft palate and watch for symmetrical elevation when the client says “aaah” ▪ Touch the posterior pharyngeal wall with a tongue depressor to elicit the gag reflex Cranial Nerve X: Vagus ▪ Sensory and motor ▪ Controls swallowing and phonation, sensation in the exterior ear’s posterior wall, and sensation behind the ear ▪ Controls sensation in the thoracic and abdominal viscera Continued 184 UNIT IV Fundamentals of Care
- 203. 7. Pupils a. Assess size, equality, and reaction to light (brisk, slow, or fixed) and note any unusual eye movements (check direct light and con- sensual light reflex); refer to Chapter 62 for abnormal pupillary findings b. This component of the neurological examina- tion may be performed during assessment of the eye. 8. Motor function a. Assess muscle tone, including strength and equality. b. Assess for voluntary and involuntary move- ments and purposeful and nonpurposeful movements. c. This component of the neurological examina- tion may be performed during assessment of the musculoskeletal system. 9. Cerebellar function a. Monitor gait as the client walks in a straight line, heel to toe (tandem walking). b. Romberg test: Client is asked to stand with the feet together and the arms at the sides and to close the eyes and hold the position; normally the client can maintain posture and balance. c. If appropriate, ask the client to perform a shallow knee bend or to hop in place on 1 leg and then the other. 10. Coordination a. Assess by asking the client to perform rapid alternating movements of the hands (e.g., turning the hands over and patting the knees continuously). b. The nurse asks the client to touch the nurse’s finger, then his or her own nose; the client keeps the eyes open and the nurse moves the finger to different spots to ensure that the client’s movements are smooth and accurate. c. Heel-to-shin test: Assist the client into a supine position, then ask the client to place the heel on the opposite knee and run it down the shin; normally the client moves the heel down the shin in a straight line. 11. Sensory function a. Pain: Assess by applying an object with a sharp point and one with a dull point to the client’s body in random order; ask the cli- ent to identify the sharp and dull feelings. b. Light touch: Brush a piece of cotton over the client’s skin at various locations in a random order and ask the client to say when the touch is felt. c. Vibration: Use a tuning fork to test the cli- ent’s ability to feel vibrations over bony prominences; ask the client to announce when the vibration starts and stops. d. Position sense (kinesthesia): Move the cli- ent’s finger or toe up or down and ask the cli- ent which way it has been moved; this tests the client’s ability to perceive passive movement. e. Stereognosis: Tests the client’s ability to rec- ognize objects placed in his or her hand f. Graphesthesia: Tests the client’s ability to identifya number traced on the client’shand g. Two-point discrimination: Tests the client’s ability to discriminate 2 simultaneous pin- pricks on the skin 12. Deep tendon reflexes a. Includes testing the following reflexes: biceps, triceps, brachioradialis, patella, Achilles b. Limb should be relaxed. c. The tendon is tapped quickly with a reflex hammer, which should cause contraction of muscle. d. Scoringdeep tendon reflexactivity(Box15-11) 13. Plantar reflex a. Acutaneous (superficial) reflex is tested with a pointed but not sharp object. b. The sole of the client’s foot is stroked from the heel, up the lateral side, and then across the ball of the foot to the medial side. c. The normal response is plantar flexion of all toes. F u n d a m e n t a l s TABLE 15-4 Assessment of the Cranial Nerves—cont’d Cranial Nerve Test Cranial Nerve XI: Spinal Accessory ▪ Motor ▪ Controls strength of neck and shoulder muscles ▪ The nurse palpates and inspects the sternocleidomastoid muscle as the client pushes the chin against the nurse’s hand ▪ The nurse palpates and inspects the trapezius muscle as the client shrugs the shoulders against the nurse’s resistance Cranial Nerve XII: Hypoglossal ▪ Motor ▪ Controls tongue movements involved in swallowing and speech ▪ Observe the tongue for asymmetry, atrophy, deviation to 1side, and fasciculations (uncontrollable twitching); ask the client to stick out the tongue (tongue should be midline) ▪ Ask the client to push the tongue against a tongue depressor, and then have the client move the tongue rapidly in and out and from side to side 185 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 204. Dorsiflexion ofthe great toe and fanning ofthe other toes (Babinski’s sign) is abnormal in anyone older than 2 years and indicates the presence ofcentralnervous sys- tem disease indicating an upper motor neuron lesion. 14. Testing for meningeal irritation a. A positive Brudzinski’s sign or Kernig’s sign indicates meningeal irritation. b. Brudzinski’s sign is tested with the client in the supine position. The nurse flexes the cli- ent’s head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion; a positive Brudzinski’s sign is observed if the client pas- sively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. c. Kernig’s sign is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. 15. Refer to Chapter 62 for additional neurological assessments and diagnostic tests. 16. Client teaching a. Client should avoid exposure to environ- mental hazards (e.g., insecticides, lead). b. High-risk behaviors that can result in head and spinal cord injuries should be avoided. c. Protective devices (e.g., a helmet, body pads) should be worn when participating in high- risk behaviors. d. Seat belts should always be worn. L. Female genitalia and reproductive tract 1. Subjective data: Urinary difficulties or symp- toms such as frequency, urgency, or burning; vaginal discharge; pain; menstrual and obstetri- cal histories; onset of menopause; medications being taken; sexual activity and the use of con- traceptives; history of sexually transmitted infections 2. Objective data a. Use a calm and relaxing approach; the examination is embarrassing for many women and may be a difficult experience for an adolescent. b. Consider the client’s cultural background and her beliefs regarding examination of the genitalia. c. A complete examination will include the external genitalia and a vaginal examination. d. The nurse’s role is to prepare the client for the examination and to assist the HCP, nurse practitioner, or nurse midwife. e. The client is asked to empty her bladder before the examination. f. The client is placed in the lithotomy position, and a drape is placed across the client. 3. External genitalia a. Quantity and distribution of hair b. Characteristics of labia majora and minora (make note of any inflammation, edema, lesions, or lacerations) c. Urethral orifice is observed for color and position. d. Vaginal orifice (introitus) is inspected for inflammation, edema, discoloration, dis- charge, and lesions. e. The examiner may check Skene’s and Bartho- lin’s glands for tenderness or discharge (if dis- charge is present, color, odor, and consistency are noted and a culture of the discharge is obtained). f. The client is assessed for the presence of a cystocele (in which a portion of the vaginal wall and bladder prolapse, or fall, into the orifice anteriorly) or a rectocele (bulging of the posterior wall of the vagina caused by pro- lapse of the rectum). 4. Speculum examination of the internal genitalia a. Performed by the HCP, nurse practitioner, or nurse midwife b. Permits visualization of the cervix and vagina c. Papanicolaou (Pap) smear (test): A painless screening test for cervical cancer is done; the specimen is obtained during the speculum examination, and the nurse helps to prepare the specimen for laboratory analysis. 5. Client teaching a. Stress the importance of personal hygiene. b. Explain the purpose and recommended fre- quency of Pap tests. c. Explain the signs of sexually transmitted infections. d. Educate the client on measures to prevent a sexually transmitted infection. e. Inform the client with a sexually transmitted infection that she must inform her sexual partner(s) of the need for an examination. M. Male genitalia 1. Subjective data: Urinary difficulty (e.g., fre- quency, urgency, hesitancy or straining, dysuria, nocturia); pain, lesions, or discharge on or from F u n d a m e n t a l s BOX 15-11 Scoring Deep Tendon Reflex Activity 0 ¼No response 1+¼Sluggish or diminished 2+¼Active or expected response 3+¼Slightly hyperactive, more brisk than normal; not neces- sarily pathological 4+¼Brisk, hyperactive with intermittent clonus associated with disease Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 2013, Mosby. 186 UNIT IV Fundamentals of Care
- 205. the penis; pain or lesions in the scrotum; medi- cations being taken; sexual activity and the use of contraceptives; history of sexually transmitted infections 2. Objective data a. Includes assessment (inspection and palpa- tion) of the external genitalia and inguinal ring and canal b. Client may stand or lie down for this examination. c. Genitalia are manipulated gently to avoid causing erection or discomfort. d. Sexual maturity is assessed by noting the size and shape of the penis and testes, the color and texture of the scrotal skin, and the charac- ter and distribution of pubic hair. e. The penis is checked for the presence of lesions or discharge; a culture is obtained if a discharge is present. f. The scrotum is inspected for size, shape, and symmetry (normally the left testicle hangs lower than the right) and is palpated for the presence of lumps. g. Inguinal ringand canal;inspection (askingthe client to bear down) and palpation are per- formed to assess for the presence of a hernia. 3. Client teaching a. Stress the importance of personal hygiene. b. Teach the client how to perform testicular self- examination (TSE); a day of the month is selected and the exam is performed on the same day each month after a shower or bath when the hands are warm and soapy and the scrotum is warm. (Refer to Chapter 48 for information on performing TSE.) c. Explain the signs of sexually transmitted infections. d. Educate the client on measures to prevent sex- ually transmitted infections. e. Inform the client with a sexually transmitted infection that he must inform his sexual part- ner(s) of the need for an examination. N. Rectum and anus 1. Subjective data: Usual bowel pattern; any change in bowel habits; rectal pain, bleeding from the rectum, or black or tarry stools; dietary habits; problems with urination; previous screening for colorectal cancer; medications being taken; history of rectal or colon problems; family his- tory of rectal or colon problems 2. Objective data a. Examination can detect colorectal cancer in its early stages; in men, the rectal examination can also detect prostate tumors. b. Women may be examined in the lithotomy position after examination of the genitalia. c. A man is best examined by having the client bend forward with his hips flexed and upper body resting over the examination table. d. A nonambulatory client may be examined in the left lateral (Sims’) position. e. The external anus is inspected for lumps or lesions, rashes, inflammation or excoriation, scars, or hemorrhoids. f. Digital examination will most likely be per- formed by the HCP or nurse practitioner. g. Digital examination is performed to assess sphincter tone; to check for tenderness, irreg- ularities, polyps, masses, or nodules in the rectal wall; and to assess the prostate gland. h. The prostate gland is normally firm, without bogginess, tenderness, or nodules (hardness or nodules may indicate the presence of a can- cerous lesion). 3. Client teaching a. Diet should include high-fiber and low-fat foods and plenty of liquids. b. The client should obtain regular digital examinations. c. The client should be able to identify the symptoms of colorectal cancer or prostatic cancer (men). d. The client should follow the American Cancer Society’s guidelines for screening for colorectal cancer. VI. Documenting Health and Physical Assessment Findings A. Documentation of findings may be either written or recorded electronically (depending on agency protocol). B. Whether written or electronic, the documentation is a legal document and a permanent record of the cli- ent’s health status. C. Principles of documentation need to be followed and data need to be recorded accurately, concisely, completely, legibly, and objectively without bias or opinions; always follow agency protocol for documentation. D. Documentation findings serve as a source of client information for other health care providers; proce- dures for maintaining confidentiality are always followed. E. Record findings about the client’s health history and physical examination as soon as possible after com- pletion of the health assessment. F. Refer to Chapter 6 for additional information about documentation guidelines. F u n d a m e n t a l s 187 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 206. F u n d a m e n t a l s CRITICALTHINK ING W hat Should Y ou Do? Answer: The carotid arteries are located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle. On assessment, the nurse should palpate 1 carotid artery at a time to avoid compromising blood flow to the brain. On auscultation, the nurse listens for the presence ofa bruit (a blowing, swish- ing sound), which indicates blood flow turbulence. Normally a bruit is not present, so this finding necessitates the need for follow-up. Both carotid arteries should be auscultated. The nurse should notify the health care provider if a bruit is detected. The nurse should also document the findings. Reference: Ignatavicius, Workman (2016), p. 639. P RACTI CE Q U ES TI O N S 132. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, “No speak English, need interpreter.” Which is the best action for the nurse to take? 1. Have one ofthe client’sfamilymembersinterpret. 2. Have the Spanish-speaking triage receptionist interpret. 3. Page an interpreter from the hospital’s inter- preter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client. 133. The nurse is performing a neurological assessment on a client and elicits a positive Romberg’s sign. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the ankle and great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4. Alack of normal sense of position when the cli- ent is unable to return extended fingers to a point of reference 134. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assess- ment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totallyirregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration 135. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A defect in the cochlea 2. A defect in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex 136. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscul- tates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise 137. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assess- ment technique to assess for muscle weakness in the eye? 1. Test the corneal reflexes. 2. Test the 6 cardinal positions of gaze. 3. Test visual acuity, using a Snellen eye chart. 4. Test sensory function by asking the client to close the eyes and then lightly touching the fore- head, cheeks, and chin. 138. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising 139. The nurse is assessing a client for meningeal irrita- tion and elicits a positive Brudzinski’s sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. 188 UNIT IV Fundamentals of Care
- 207. 140. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished 141. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client’s temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client’s respirations 5. Performing a musculoskeletal and neurolog- ical examination 6. Asking the client about a family history of any illness or disease AN S WERS 132. 3 Rationale: The best action is to have a professional hospital- based interpreter translate for the client. English-speaking fam- ily members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non–health care provider acts as interpreter. Test-Taking Strategy: Note the strategic word, best. Ini- tially focus on what the client needs. In this case the client needs and asks for an interpreter. Next keep in mind the issue of confidentiality and making sure that information is obtained in the most efficient and accurate way. This will assist in eliminating options 1, 2, and 4. Review: Actions to take to address language barriers Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Communication; Culture Reference: Jarvis (2016), pp. 45-46. 133. 3 Rationale: In Romberg’s test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain pos- ture and balance. Apositive Romberg’s sign is a vestibular neu- rological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. Apositive gaze nystag- mus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski’s test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease. Test-Taking Strategy: Note the subject, Romberg’s sign. You can easily answer this question if you can recall that the client’s balance is tested in this test. Review: Romberg’s test Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Mobility References: Ignatavicius, Workman (2016), p. 842; Jarvis (2016), p. 650. 134. 1 Rationale: Cheyne-Stokes respirations are rhythmic respira- tions with periods of apnea and can indicate a metabolic dys- function in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sus- tained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irreg- ular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons. Test-Taking Strategy: Focus on the subject, the characteris- tics of Cheyne-Stokes respirations. Recalling that periods of apnea occur with this type of respiration will help direct you to the correct answer. Review: Cheyne-Stokes respirations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Gas Exchange Reference: Jarvis (2016), p. 444. 135. 3 Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. Asen- sorineural hearing loss occurs as a result of a pathological pro- cess in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex. Test-Taking Strategy: Focus on the subject, a conductive hearing loss. Noting the relationship of the word conductive in the question and transmission in the correct option will direct you to this option. Review: Conductive hearing loss and sensorineural hear- ing loss F u n d a m e n t a l s 189 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 208. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Client Education; Sensory Perception Reference: Ignatavicius, Workman (2016), p. 1009. 136. 3 Rationale: Aheart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound. Test-Taking Strategy: Focus on the subject, characteristics of a murmur. Eliminate option 1 because it describes normal heart sounds. Next recall that a murmur occursas a result ofthe man- ner in which the blood is flowing through the cardiac cham- bers and valves. This will direct you to the correct option. Review: Heart murmur Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Perfusion References: Ignatavicius, Workman (2016), p. 640; Jarvis (2016), pp. 464, 506. 137. 2 Rationale: Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal). Test-Taking Strategy: Focus on the subject, assessing for muscle weakness in the eyes. Note the relationship between the words extraocular movements in the question and positions of gaze in the correct option. Review: Physical assessment techniques for muscle weakness in the eyes Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Sensory Perception References: Ignatavicius, Workman (2016), pp. 972-973; Jarvis (2016), p. 313. 138. 1 Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSEisafter a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify anyabnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE. Test-Taking Strategy: Note the strategic word, best. Think about the purpose of this test and visualize this assessment technique to answer correctly. Review: Testicular self-examination Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Client Education; Sexuality References: Ignatavicius, Workman (2016), p. 1513; Jarvis (2016), pp. 704-705. 139. 3 Rationale: Brudzinski’s sign is tested with the client in the supine position. The nurse flexesthe client’s head (gentlymoves the head to the chest) and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski’s sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral col- umn. Kernig’s sign also tests for meningeal irritation and is pos- itive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed. Test-Taking Strategy: Focus on the subject, a positive Brud- zinski’s sign. Recalling that a positive sign is elicited if the client reports pain will assist in eliminating options 1 and 4. Next it is necessaryto know that a positive Brudzinski’s sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Review: Brudzinski’s sign Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Intracranial Regulation Reference: Jarvis (2016), p. 688. 140. 3 Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing.Wheezesaredescribed ashigh-pitched musicalsounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency.Cracklesareproduced byairpassingoverretained air- way secretions or fluid, or the sudden opening of collapsed F u n d a m e n t a l s 190 UNIT IV Fundamentals of Care
- 209. airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Test-Taking Strategy: Note the subject, assessment ofabnor- mal lung sounds. Note the client’s diagnosis and think about the pathophysiology that occurs in this disorder. Recalling that bron- chial constriction occurs will assist in directing you to the correct option. Also, thinking about the definition of each adventitious lung sound identified in the options will direct you to the correct option. Review: Adventitious lung sounds Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Gas Exchange References: Ignatavicius, Workman (2016), pp. 506-507; Jarvis (2016), p. 447. 141. 1, 2, 4 Rationale: A focused assessment focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relatesto a vascularassessment,which isnot related to thisclient’s complaints. A musculoskeletal and neurological examination also is not related to this client’s complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment. Test-Taking Strategy: Focus on the subject and note the words focused assessment. Noting that the client’s symptoms relate to the respiratory system and the presence of an infection will direct you to the correct options. Review: Focused assessments Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process—Assessment Content Area: Developmental Stages—Health Assessment/ Physical Exam Priority Concepts: Clinical Judgment; Gas Exchange References: Jarvis (2016), p. 7; Lewis et al. (2014), pp. 44-45. F u n d a m e n t a l s 191 CHAPTER 15 Health and Physical Assessment of the Adult Client
- 210. F u n d a m e n t a l s CH AP TER 16 Provision of a Safe Environment PRIORITYCONCEPTS Infection, Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse is working in a long-term care facilitythat has a “no restraint policy.” An assigned client is disoriented and unsteadyand continuallyattempts to climb out of bed. What should the nurse do with regard to instituting safety precau- tions for this client? Answer located on p. 199. I. Environmental Safety A. Fire safety (see Priority Nursing Actions) PRIORITYNURSING ACTIONS Event of a Fire 1. Rescue clients who are in immediate danger. 2. Activate the fire alarm. 3. Confine the fire. 4. Extinguish the fire. a. Obtain the fire extinguisher. b. Pull the pin on the fire extinguisher. c. Aim at the base of the fire. d. Squeeze the extinguisher handle. e. Sweep the extinguisher from side to side to coat the area of the fire evenly. Remember the mnemonic RACEto prioritize in the event of a fire. R is rescue clients in immediate danger, A is alarm (sound the alarm), C is confine the fire by closing all doors, and E is extinguish. To properly use the fire extinguisher, remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P is pull the pin, A is aim at the base of the fire, S is squeeze the handle, and S is sweep from side to side to coat the area evenly. Reference Perry, Potter, Ostendorf (2014), pp. 313-314. 1. Keep open spaces free of clutter. 2. Clearly mark fire exits. 3. Know the locations of all fire alarms, exits, and extinguishers (Table 16-1; also see Priority Nursing Actions). 4. Know the telephone number for reporting fires. 5. Know the fire drill and evacuation plan of the agency. 6. Never use the elevator in the event of a fire. 7. Turn off oxygen and appliances in the vicinity of the fire. 8. In the event of a fire, if a client is on life support, maintain respiratory status manually with an Ambu bag (resuscitation bag) until the client is moved away from the threat of the fire and can be placed back on life support. 9. In the event of a fire, ambulatory clients can be directed to walk by themselves to a safe area and, in some cases, may be able to assist in mov- ing clients in wheelchairs. 10. Bedridden clients generally are moved from the scene of a fire by stretcher, their bed, or wheelchair. 11. If a client must be carried from the area of a fire, appropriate transfer techniques need to be used. 12. If fire department personnel are at the scene of the fire, they will help to evacuate clients. Remember the mnemonic RACE (Rescue clients, Activate the fire alarm, Confine the fire, Extinguish the fire) to set priorities in the event of a fire and the mne- monic PASS (Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep from side to side) to use a fire extinguisher. B. Electrical safety 1. Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. 2. Use a 3-pronged electrical cord. 192
- 211. F u n d a m e n t a l s 3. In a 3-pronged electrical cord, the third, longer prong of the cord is the ground; the other 2 prongs carry the power to the piece of electrical equipment. 4. Check electrical cords and outlets for exposed, frayed, or damaged wires. 5. Avoid overloading any circuit. 6. Read warning labels on all equipment; never operate unfamiliar equipment. 7. Use safety extension cords only when absolutely necessary, and tape them to the floor with electrical tape. 8. Never run electrical wiring under carpets. 9. Never pull a plug by using the cord; always grasp the plug itself. 10. Never use electrical appliances near sinks, bath- tubs, or other water sources. 11. Always disconnect a plug from the outlet before cleaning equipment or appliances. 12. If a client receives an electrical shock, turn off the electricity before touching the client. Any electrical equipment that the client brings into the health care facility must be inspected for safety before use. C. Radiation safety 1. Know the protocols and guidelines of the health care agency. 2. Label potentially radioactive material. 3. To reduce exposure to radiation, do the following. a. Limit the time spent near the source. b. Make the distance from the source as great as possible. c. Use a shielding device such as a lead apron. 4. Monitor radiation exposure with a film (dosimeter) badge. 5. Place the client who has a radiation implant in a private room. 6. Never touch dislodged radiation implants. 7. Keep all linens in the client’s room until the implant is removed. D. Disposal of infectious wastes 1. Handle all infectious materials as a hazard. 2. Dispose of waste in designated areas only, using proper containers for disposal. 3. Ensure that infectious material is labeled properly. 4. Dispose of all sharps immediately after use in closed, puncture-resistant disposal containers that are leak-proof and labeled or color-coded. Needles (sharps) should not be recapped, bent, or broken because of the risk of accidental injury (needle stick). E. Physiological changes in the older client that increase the risk of accidents (Box 16-1) F. Risk for falls assessment 1. Should be client-centered and include the use of a fall risk scale per agency procedures 2. Include the client’s own perceptions of their risk factors for falls and their method to adapt to these factors. Areas of concern may include gait stability, muscle strength and coordination, bal- ance, and vision. 3. Assess for any previous accidents. 4. Assess with the client any concerns about their immediate environment, including stairs, use of throw rugs, grab bars, or a raised toilet seat. 5. Review the medications that the client is taking that could have a side or adverse effect or side/ adverse effects that could place the client at risk for a fall. 6. Determine any scheduled procedures that pose risks to the client. G. Measures to prevent falls (Box 16-2) H. Measures to promote safety in ambulation for the client TABLE 16-1 Types of Fire Extinguishers Type Class of Fire A Wood, cloth, upholstery, paper, rubbish, plastic B Flammable liquids or gases, grease, tar, oil-based paint C Electrical equipment BOX16-1 Physiological Changes in Older Clients That Increase the Risk of Accidents Musculoskeletal Changes Strength and function of muscles decrease. Joints become less mobile and bones become brittle. Postural changes and limited range of motion occur. Nervous System Changes Voluntary and autonomic reflexes become slower. Decreased ability to respond to multiple stimuli occurs. Decreased sensitivity to touch occurs. Sensory Changes Decreased vision and lens accommodation and cataracts develop. Delayed transmission of hot and cold impulses occurs. Impaired hearing develops, with high-frequency tones less perceptible. Genitourinary Changes Increased nocturia and occurrences of incontinence may occur. Adapted from Potter A, Perry P, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby; and Touhy T, Jett K: Ebersole and Hess’ toward healthy aging, ed 8, St. Louis, 2012, Mosby. 193 CHAPTER 16 Provision of a Safe Environment
- 212. 1. Gait belt may be used to keep the center of gravity midline. a. Place the belt on the client prior to ambulation. b. Encircle the client’s waist with the belt. c. Hold on to the side or back of the belt so that the client does not lean to 1 side. d. Return the client to bed or a nearby chair if the client develops dizziness or becomes unsteady. I. Steps to prevent injury to the health care worker (Box 16-3) J. Restraints (safety devices) 1. Restraints (safety devices) are protective devices used to limit the physical activity of a client or to immobilize a client or an extremity. a. The agency policy should be checked when applying side rails. b. The use of side rails is not considered a restraint when they are used to prevent a sedated client from falling out of bed. c. The client must be able to exit the bed easily in case of an emergency when using side rails. Only the top 2 side rails should be used. d. The bed must be kept the in the lowest posi- tion when using side rails. 2. Physical restraints restrict client movement through the application of a device. 3. Chemical restraints are medications given to inhibit a specific behavior or movement. 4. Interventions a. Use alternative devices, such as pressure- sensitive beds or chair pads with alarms or other types of bed or chair alarms, whenever possible. b. If restraints are necessary, the health care pro- vider’s (HCP’s) prescriptions should state the type of restraint, identify specific client behav- iors for which restraints are to be used, and identify a limited time frame for use. c. The HCP’s prescriptions for restraints should be renewed within a specific time frame according to agency policy. d. Restraints are not to be prescribed PRN (as needed). e. The reason for the safety device should be given to the client and the family, and their permission should be sought. f. Restraints should not interfere with any treat- ments or affect the client’s health problem. g. Use a half-bow or safety knot (quick release tie) or a restraint with a quick release buckle to secure the device to the bed frame or chair, not to the side rails. h. Ensure that there is enough slack on the straps to allow some movement of the body part. i. Assess skin integrity and neurovascular and circulatory status every 30 minutes and remove the safety device at least every 2 hours to permit muscle exercise and to promote cir- culation (follow agency policies). j. Continually assess and document the need for safety devices (Box 16-4). k. Offer fluids if clinically indicated every 2 hours. l. Offer bedpan or toileting every 2 hours. An HCP’s prescription for use of a safety device (restraint) is needed. Alternative measures for safety devices should always be used first. 5. Alternatives to safety devices a. Orient the client and family to the surroundings. b. Explain all procedures and treatments to the client and family. c. Encourage family and friends to stay with the client, and use sitters for clients who need supervision. F u n d a m e n t a l s BOX 16-2 Measures to Prevent Falls ▪ Assess the client’s risk for falling. ▪ Assign the client at risk for falling to a room near the nurses’ station. ▪ Alert all personnel to the client’s risk for falling. ▪ Assess the client frequently. ▪ Orient the client to physical surroundings. ▪ Instruct the client to seek assistance when getting up. ▪ Explain the use of the nurse call system. ▪ Use safety devices such as floor pads, and bed or chair alarms that alert health care personnel of the person get- ting out of bed or a chair. ▪ Keep the bed in the low position with side rails adjusted to a safe position (follow agency policy). ▪ Lock all beds, wheelchairs, and stretchers. ▪ Keep clients’ personal items within their reach. ▪ Eliminate clutter and obstacles in the client’s room. ▪ Provide adequate lighting. ▪ Reduce bathroom hazards. ▪ Maintain the client’s toileting schedule throughout the day. BOX 16-3 Steps to Prevent Injury to the Health Care Worker When Moving a Client ▪ Use available safety equipment. ▪ Keep the weight to be lifted as close to the body as possible. ▪ Bend at the knees. ▪ Tighten abdominal muscles and tuck the pelvis. ▪ Maintain the trunk erect and knees bent so that multiple muscle groups work together in a coordinated manner. Adapted from Potter A, Perry P, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 194 UNIT IV Fundamentals of Care
- 213. d. Assign confused and disoriented clients to rooms near the nurses’ station. e. Provide appropriate visual and auditory stim- uli, such as a night light, clocks, calendars, television, and a radio, to the client. f. Place familiar items, such as family pictures, near the client’s bedside. g. Maintain toileting routines. h. Eliminate bothersome treatments, such as nasogastric tube feedings, as soon as possible. i. Evaluate all medications that the client is receiving. j. Use relaxation techniques with the client. k. Institute exercise and ambulation schedules as the client’s condition allows. l. Collaborate with the HCP to evaluate oxygen- ation status, vital signs, electrolyte/laboratory values, and other pertinent assessment find- ings that may provide information about the cause of the client’s confusion. K. Poisons 1. A poison is any substance that impairs health or destroys life when ingested, inhaled, or other- wise absorbed by the body. 2. Specific antidotes or treatments are available only for some types of poisons. 3. The capacity of body tissue to recover from a poi- son determines the reversibility of the effect. 4. Poison can impair the respiratory, circulatory, central nervous, hepatic, gastrointestinal, and renal systems of the body. 5. The toddler, the preschooler, and the young school-age child must be protected from acciden- tal poisoning. 6. In older adults, diminished eyesight and impaired memory may result in accidental inges- tion of poisonous substances or an overdose of prescribed medications. 7. A Poison Control Center phone number should be visible on the telephone in homes with small children; in all cases of suspected poisoning, the number should be called immediately. 8. Interventions a. Remove any obvious materials from the mouth, eyes, or body area immediately. b. Identify the type and amount of substance ingested. c. Call the Poison Control Center before attempting an intervention. d. If the victim vomits or vomiting is induced, save the vomitus if requested to do so, and deliver it to the Poison Control Center. e. If instructed by the Poison Control Center to take the person to the emergency department, call an ambulance. f. Never induce vomiting following ingestion of lye, household cleaners, grease, or petroleum products. g. Never induce vomiting in an unconscious victim. The Poison Control Center should be called first before attempting an intervention. II. Health Care–Associated (Nosocomial) Infections A. Health care–associated (nosocomial) infections also are referred to as hospital-acquired infections. B. These infections are acquired in a hospital or other health care facility and were not present or incubat- ing at the time of a client’s admission. C. Clostridium difficile is spread mainly by hand-to-hand contact in a health care setting. Clients takingmultiple antibiotics for a prolonged period are most at risk. D. Common drug-resistant infections: Vancomycin- resistant enterococci, methicillin-resistant Staphylo- coccus aureus, multidrug-resistant tuberculosis, carbapenem-resistant Enterobacteriaceae (CRE) E. Illness and some medications such as immunosup- pressants impair the normal defense mechanisms. F. The hospital environment provides exposure to a variety of virulent organisms that the client has not been exposed to in the past; therefore, the client has not developed resistance to these organisms. G. Infections can be transmitted by health care person- nel who fail to practice proper hand-washing proce- dures or fail to change gloves between client contacts. H. At many health care agencies, dispensers containing an alcohol-based solution for hand sanitization are mounted at the entrance to each client’s room; it is important to note that alcohol-based sanitizers are not effective against some infectious agents such as Clostridium difficile spores. III. Standard Precautions A. Description 1. Nurses must practice standard precautions with all clients in any setting, regardless of the diagno- sis or presumed infectiveness. 2. Standard precautions include hand washing and the use of gloves, masks, eye protection, and gowns, when appropriate, for client contact. F u n d a m e n t a l s BOX 16-4 Documentation Points with Use of a Safety Device (Restraint) ▪ Reason for safety device ▪ Method of use for safety device ▪ Date and time of application of safety device ▪ Duration of use of safety device and client’s response ▪ Release from safetydevice with periodic exercise and circu- latory, neurovascular, and skin assessment ▪ Assessment of continued need for safety device ▪ Evaluation of client’s response 195 CHAPTER 16 Provision of a Safe Environment
- 214. F u n d a m e n t a l s 3. These precautions apply to blood, all body fluids (whether or not they contain blood), secretions and excretions, nonintact skin, and mucous membranes. B. Interventions 1. Wash hands between client contacts; after con- tact with blood, body fluids, secretions or excre- tions, nonintact skin, or mucous membranes; after contact with equipment or contaminated articles; and immediately after removing gloves. 2. Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes,or contaminated items;remove gloves and wash hands between client care contacts. 3. For routine decontamination of hands, use alcohol-based hand rubs when hands are not vis- ibly soiled. For more information on hand hygiene from the Centers for Disease Control and Prevention (CDC), see www.cdc.gov/ handhygiene/ 4. Wear masks and eye protection, or face shields, if client care activities may generate splashes or sprays of blood or body fluid. 5. Wear gowns if soiling of clothing is likely from blood or body fluid; wash hands after removing a gown. 6. Steps for donning and removing personal protec- tive equipment (PPE) (Table 16-2) 7. Clean and reprocess client care equipment prop- erly and discard single-use items. 8. Place contaminated linens in leak-proof bags and limit handling to prevent skin and mucous membrane exposure. 9. Use needleless devices or special needle safety devices whenever possible to reduce the risk of needle sticks and sharps injuries to health care workers. 10. Discard all sharp instruments and needles in a puncture-resistant container; dispose of needles uncapped or engage the safety mechanism on the needle if available. 11. Clean spills of blood or body fluids with a solu- tion of bleach and water (diluted 1:10) or agency-approved disinfectant. Handle all blood and body fluids from all clients as if they were contaminated. IV. Transmission-Based Precautions A. Transmission-based precautions include airborne, droplet, and contact precautions. B. Airborne precautions 1. Diseases a. Measles b. Chickenpox (varicella) c. Disseminated varicella zoster d. Pulmonary or laryngeal tuberculosis 2. Barrier protection a. Single room is maintained under negative pressure; door remains closed except upon entering and exiting. b. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges per hour via high-efficiency particulate air (HEPA) filtration maskoraccordingto agencyprotocol. c. Ultraviolet germicide irradiation or HEPA fil- ter is used in the room. d. Health care workers wear a respiratory mask (N95 or higher level). A surgical mask is placed on the client when the client needs to leave the room; the client leaves the room only if necessary. C. Droplet precautions 1. Diseases a. Adenovirus b. Diphtheria (pharyngeal) c. Epiglottitis d. Influenza (flu) e. Meningitis f. Mumps g. Mycoplasmal pneumonia or meningococcal pneumonia TABLE 16-2 Steps for Donning and Removing Personal Protective Equipment (PPE) Donning of PPE Removal of PPE* Gown Gloves Fully cover front of body from neck to knees and upper arms to end of wrist Fasten in the back at neck and waist, wrap around the back Grasp outside of glove with opposite hand with glove still on and peel off Hold on to removed glove in gloved hand Slide fingers of ungloved hand under clean side of remaining glove at wrist and peel off Mask or Respirator Goggles/Face Shield Secure ties or elastic band at neck and middle of head Fit snug to face and below chin Fit to nose bridge Respirator fit should be checked per agency policy Remove bytouching clean band or inner part Goggles/Face Shield Gown Adjust to fit according to agency policy Unfasten at neck, then at waist Remove using a peeling motion, pulling gown from each shoulder toward the hands Allow gown to fall forward, and roll into a bundle to discard Gloves Mask or Respirator Select appropriate size and extend to cover wrists of gown Grasp bottom ties then top ties to remove *Note: All equipment is considered contaminated on the outside. 196 UNIT IV Fundamentals of Care
- 215. h. Parvovirus B19 i. Pertussis j. Pneumonia k. Rubella l. Scarlet fever m. Sepsis n. Streptococcal pharyngitis 2. Barrier protection a. Private room or cohort client (a client whose body cultures contain the same organism) b. Wear a surgical mask when within 3 feet of a client. c. Place a mask on the client when the client needs to leave the room. D. Contact precautions 1. Diseases a. Colonization or infection with a multidrug- resistant organism b. Enteric infections, such as Clostridium difficile c. Respiratory infections, such as respiratory syncytial virus d. Influenza: Infection can occur by touching something with flu viruses on it and then touching the mouth or nose. e. Wound infections f. Skin infections, such as cutaneous diphtheria, herpes simplex, impetigo, pediculosis, sca- bies, staphylococci, and varicella zoster g. Eye infections, such as conjunctivitis h. Indirect contact transmission may occur when contaminated object or instrument, or hands, are encountered. 2. Barrier protection a. Private room or cohort client b. Use gloves and a gown whenever entering the client’s room. V. Emergency Response Plan and Disasters A. Know the emergency response plan of the agency. B. Internal disasters are those that occur within the health care facility. C. External disasters occur in the community, and vic- tims are brought to the health care facility for care. D. When the health care facility is notified of a disaster, the nurse should follow the guidelines specified in the emergency response plan of the facility. E. See Chapter 7 for additional information on disaster planning. In the event of a disaster, the emergency response plan is activated immediately. VI. Biological Warfare Agents A. Awarfare agent is a biological or chemical substance that can cause mass destruction or fatality. B. Anthrax (Fig. 16-1) 1. The disease is caused by Bacillusanthracisand can be contracted through the digestive system, abra- sions in the skin, or inhalation through the lungs. 2. Anthrax is transmitted by direct contact with bac- teria and spores; spores are dormant encapsulated bacteria that become active when they enter a liv- ing host (no person-to-person spread) (Box16-5). 3. The infection is carried to the lymph nodes and then spreads to the rest of the body by way of the blood and lymph; high levels of toxins lead to shock and death. 4. In the lungs, anthrax can cause buildup of fluid, tissue decay, and death (fatal if untreated). 5. Ablood test is available to detect anthrax (detects and amplifies Bacillus anthracis DNAif present in the blood sample). 6. Anthraxis usually treated with antibiotics such as ciprofloxacin, doxycycline, or penicillin. 7. The vaccine for anthrax has limited availability. F u n d a m e n t a l s FIGURE 16-1 Anthrax. (From Swartz, 2010.) BOX16-5 Anthrax: Transmission and Symptoms Skin Spores enter the skin through cuts and abrasions and are con- tracted by handling contaminated animal skin products. Infection starts with an itchy bump like a mosquito bite that progresses to a small liquid-filled sac. The sac becomes a painless ulcer with an area of black, dead tissue in the middle. Toxins destroy surrounding tissue. Gastrointestinal Infection occurs following the ingestion of contaminated undercooked meat. Symptoms begin with nausea, loss of appetite, and vomiting. The disease progresses to severe abdominal pain, vomiting of blood, and severe diarrhea. Inhalation Infection is caused bythe inhalation ofbacterial spores, which multiply in the alveoli. The disease begins with the same symptoms as the flu, includ- ing fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the develop- ment of breathing problems and shock. Toxins cause hemorrhage and destruction of lung tissue. 197 CHAPTER 16 Provision of a Safe Environment
- 216. C. Smallpox (Fig. 16-2) 1. Smallpox is transmitted in air droplets and by handling contaminated materials and is highly contagious. 2. Symptoms begin 7 to 17 days after exposure and include fever, back pain, vomiting, malaise, and headache. 3. Papules develop 2 days after symptoms develop and progress to pustular vesicles that are abun- dant on the face and extremities initially. 4. Avaccine is available to those at risk for exposure to smallpox. D. Botulism 1. Botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostrid- ium botulinum (death can occur within 24 hours). 2. Its spores are found in the soil and can spread through the air or food (improperly canned food) or via a contaminated wound. 3. Botulism cannot be spread from person to person. 4. Symptoms include abdominal cramps, diarrhea, nausea and vomiting, double vision, blurred vision, drooping eyelids, difficulty swallowing or speaking, dry mouth, and muscle weakness. 5. Neurological symptoms begin 12 to 36 hours after ingestion of food-borne botulism and 24 to 72 hours after inhalation and can progress to paralysis of the arms, legs, trunk, or respiratory muscles (mechanical ventilation is necessary). 6. If diagnosed early, food-borne and wound botu- lism can be treated with an antitoxin that blocks the action of toxin circulating in the blood. 7. Other treatments include induction of vomiting, enemas, and penicillin. 8. No vaccine is available. E. Plague 1. Plague is caused by Yersinia pestis, a bacteria found in rodents and fleas. 2. Plague is contracted by being bitten by a rodent or flea that is carrying the plague bacterium, by the ingestion of contaminated meat, or by han- dling an animal infected with the bacteria. 3. Transmission isbydirect person-to-person spread. 4. Forms include bubonic (most common), pneu- monic, and septicemic (most deadly). 5. Symptoms usually begin within 1 to 3 days and include fever, chest pain, lymph node swelling, and a productive cough (hemoptysis). 6. The disease rapidly progresses to dyspnea, stri- dor, and cyanosis; death occurs from respiratory failure, shock, and bleeding. 7. Antibiotics are effective only if administered immediately; the usual medications of choice include streptomycin or gentamicin. 8. A vaccine is available. F. Tularemia 1. Tularemia (also called deer flyfever or rabbit fever) is an infectious disease of animals caused by the bacillus Francisella tularensis. 2. The disease is transmitted by ticks, deer flies, or contact with an infected animal. 3. Symptoms include fever, headache, and an ulcer- ated skin lesion with localized lymph node enlargement, eye infections, gastrointestinal ulcerations, or pneumonia. 4. Treatment is with antibiotics. 5. Recovery produces lifelong immunity (a vaccine is available). G. Hemorrhagic fever 1. Hemorrhagic fever is caused by several viruses, including Marburg, Lassa, Junin, and Ebola. 2. The virus is carried by rodents and mosquitoes. 3. The disease can be transmitted directly by person-to-person spread via body fluids. 4. Symptoms include fever, headache, malaise, con- junctivitis, nausea, vomiting, hypotension, hem- orrhage of tissues and organs, and organ failure. 5. No known specific treatment is available; treat- ment is symptomatic. H. Ebola Virus Disease (EVD) 1. Previously known as Ebola hemorrhagic fever 2. Caused by infection with a virus of the family Filoviridae, genus Ebolavirus 3. First discovered in 1976 in theDemocraticRepublic of the Congo. Outbreaks have appeared in Africa. 4. The natural reservoir host of Ebolavirus remains unknown. It is believed that the virus is animal- borne and that bats are the most likely reservoir. 5. Spread of the virus is through contact with objects (such as clothes, bedding, needles, syrin- ges/sharps, or medical equipment) that have been contaminated with the virus. 6. Symptoms similar to hemorrhagic fever may appear from 2 to 21 days after exposure. 7. Assessment: Ask the client if he or she traveled to an area with EVD such as Guinea, Liberia, or Sierra Leone within the last 21 days or if he or she has had contact with someone with EVD and had any of the following symptoms: F u n d a m e n t a l s FIGURE 16-2 Smallpox. (Courtesy Centers for Disease Control and Pre- vention [CDC]: Evaluating patients for smallpox. Atlanta, 2002, CDC.) 198 UNIT IV Fundamentals of Care
- 217. a. Feverat homeora current temperature of38 °C (100.4 °F) or greater b. Severe headache c. Muscle pain d. Weakness e. Fatigue f. Diarrhea g. Vomiting h. Abdominal pain i. Unexplained bleeding or bruising 8. Interventions a. If the assessment indicates possible infection with EVD, the client needs to be isolated in a private room with a private bathroom or a cov- ered bedside commode with the door closed. b. Health careworkersneed to weartheproperPPE and follow updated procedures designated by the Centers for Disease Control and Prevention for donning (putting on) and doffing (remov- ing) PPE. Refer to the following Web site for updated information: http://www.cdc.gov/ vhf/ebola/healthcare-us/ppe/guidance.html c. The number of health care workers entering the room should be limited and a log of everyone who enters and leaves the room should be kept. d. Only necessary tests and procedures should be performed, and aerosol-generating proce- dures should be avoided. e. Refer to the CDC guidelines for cleaning, dis- infecting, and managing waste (www.cdc. gov/vhf/ebola/healthcare-us/cleaning/ hospitals.html). f. The agency’s infection control program should be notified, and state and local public health authoritiesshould be notified. Alist ofthe state and local health department numbers is avail- able at www.cdc.gov/vhf/ebola/outbreaks/ state-local-health-department-contacts.html Anthrax is transmitted by direct contact with bacteria and spores and can be contracted through the digestive system, abrasions in the skin, or inhalation through the lungs. VII. Chemical Warfare Agents A. Sarin 1. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. 2. It enters the body through the eyes and skin and acts by paralyzing the respiratory muscles. B. Phosgene is a colorless gas normally used in chemical manufacturing that if inhaled at high concentrations for a long enough period will lead to severe respira- tory distress, pulmonary edema, and death. C. Mustard gas is yellow to brown and has a garliclike odor that irritates the eyes and causes skin burns and blisters. D. Ionizing radiation 1. Acute radiation exposure develops after a sub- stantial exposure to radiation. 2. Exposure can occur from external radiation or internal absorption. 3. Symptoms depend on the amount of exposure to the radiation and range from nausea and vomiting, diarrhea, fever, electrolyte imbal- ances, and neurological and cardiovascular impairment to leukopenia, purpura, hemor- rhage, and death. VIII. Nurse’s Role in Exposure to Warfare Agents A. Be aware that, initially, a bioterrorism attack may resemble a naturally occurring outbreak of an infec- tious disease. B. Nurses and other health care workers must be pre- pared to assess and determine what type of event occurred, the number of clients who may be affected, and how and when clients will be expected to arrive at the health care agency. C. It is essential to determine any changes in the microorganism that may increase its virulence or make it resistant to conventional antibiotics or vaccines. D. See Chapter 7 for additional information on disas- ters and emergency response planning. F u n d a m e n t a l s CRITICALTHINK ING W hat Should Y ou Do? Answer: Manyfacilities implement a “no restraint policy,” which requires health care workers to implement other safety strategies for clients who pose a risk for falls. These strategies include orienting the client and family to the surroundings; explaining allprocedures and treatments to the client and fam- ily; encouraging family and friends to stay with the client as appropriate and using sitters for clients who need supervision; assigning confused and disoriented clients to rooms near the nurses’station;providingappropriate visualand auditorystim- uli to the client, such as a night light, clocks, calendars, televi- sion, and a radio; maintaining toileting routines; eliminating bothersome treatments,such as tube feedings, as soon as pos- sible; evaluating all medications that the client is receiving; using relaxation techniques with the client;and instituting exer- cise and ambulation schedules as the client’s condition allows. Some agencies are instituting certain policies, such as hourly rounding, to ensure client safety. With hourlyrounding, nurses and unlicensed assistive personnel are required to check the client to address the 5 Ps— problem, pain, positioning, potty, and possessions— everyhour. This helps to eliminate the need to call for assistance and ensures that the client’s basic needs are being met in a timelymanner. Reference: Perry, Potter, Ostendorf (2014), pp. 304, 307. 199 CHAPTER 16 Provision of a Safe Environment
- 218. P RACTI CE Q U ES TI O N S 142. The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chlo- ride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses’ lounge for the pump plug. 143. The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indi- cate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client’s skin 144. The community health nurse is providing a teach- ing session about anthrax to members of the com- munity and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effec- tive? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion ofcontaminated undercooked meat 145. The nurse is giving a report to an unlicensed assis- tive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes 146. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which inter- vention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client’s bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway 147. Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield 148. The nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door. 149. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department. 150. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central sup- ply department. 4. Obtain additional nursing staff to assist in treat- ing the casualties. F u n d a m e n t a l s 200 UNIT IV Fundamentals of Care
- 219. 151. The nurse is caring for a client with meningitis and implements which transmission-based precau- tions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room 152. The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client’s temperature. 2. Contact the health care provider. 3. Isolate the client in a private room. 4. Check a complete set of vital signs. AN S WERS 142. 2 Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IVline that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard. Test-Taking Strategy: Note the subject, electrical safety. Recal- ling safety issues will direct you to the correct option. Contact- ing the maintenance department is the only correct option since the other options are not considered safe practice when implementing electrical actions. In addition, since potassium chloride is in the IV solution, a pump must be used. Review: Electrical safety Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), p. 314. 143. 2 Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client’s skin. Test-Taking Strategy: Focus on the subject, the unsafe inter- vention. Also note the strategic words, further instruction is required. These words indicate a negative event query and the need to select the incorrect option. Read each option carefully. The words securing the safety device straps to the side rails in option 2 should direct your attention to this as an incorrect and unsafe action. Review: Safety device application Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Safety Priority Concepts: Health Care Quality; Safety Reference: Perry, Potter, Ostendorf (2014), p. 310. 144. 2, 3, 6 Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies. Test-Taking Strategy: Focus on the subject, routes of transmis- sion of anthrax. Knowledge regarding the methods of contract- ing anthrax is needed to answer this question. Remember that it is not spread by person-to-person contact or contracted via tick or deer fly bites. Review: Anthrax Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Infection Control Priority Concepts: Client Teaching; Infection Reference: Ignatavicius, Workman (2016), p. 411. 145. 4 Rationale: The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed. Test-Taking Strategy: Focus on the subject, checking skin integrity of a client with safety devices. In this situation, select- ing the option that identifies the most frequent time frame is best. Review: Safety device guidelines Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management—Delegating Priority Concepts: Health Care Quality; Safety Reference: Perry, Potter, Ostendorf (2014), p. 311. 146. 4 Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure. Test-Taking Strategy: Note the strategic words, indicates the need for revision. These words indicate a negative event query F u n d a m e n t a l s 201 CHAPTER 16 Provision of a Safe Environment
- 220. and the need to select the incorrect nursing intervention. Remember that the client with an internal radiation implant needs to be placed in a private room. Review: Radiation safety principles Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Safety Priority Concepts: Health Care Quality; Safety Reference: Ignatavicius, Workman (2016), p. 376. 147. 4 Rationale: Splashes of body secretions can occur when provid- ing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precau- tions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary. Test-Taking Strategy: Focus on the subject, protective items needed to perform colostomy care. Also, note the words contact precautions. Visualize care for this client to determine the nec- essary items required for self-protection. This will direct you to the correct option. Review: Transmission-based precautions Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Infection Control Priority Concepts: Clinical Judgment; Safety Reference: Ignatavicius, Workman (2016), pp. 403-404, 453. 148. 3 Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished. Test-Taking Strategy: Note the strategic word, next. Remem- ber the mnemonic RACE to prioritize in the event of a fire. R is rescue clients in immediate danger, A is alarm (sound the alarm), C is confine the fire by closing all doors, and E is extin- guish or evacuate. Review: Fire safety Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 313-314. 149. 3 Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance. Test-Taking Strategy: Note the strategic word, immediate. Calling the Poison Control Center is the first action since it will direct the mother on the next step to take based on the type of poisoning. The other options are unsafe or could cause a delay in treatment. Review: Poison control measures Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Clinical Judgment; Safety Reference: Hockenberry, Wilson (2015), pp. 545, 548. 150. 2 Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to acti- vate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur. Test-Taking Strategy: Note the strategic word, initial, and determine the priority action. Note that the correct option is the umbrella option. The emergency response plan includes all of the other options. Review: Disaster preparedness Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Clinical Judgment; Safety Reference: Ignatavicius, Workman (2016), pp. 140-143. 151. 1 Rationale: Meningitis is transmitted by droplet infection. Pre- cautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room. Test-Taking Strategy: Focus on the subject, the correct precau- tion needs for a client with meningitis. Recalling that meningi- tis is transmitted by droplets will direct you to the correct option. Review: Transmission-based precautions Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Infection Control Priority Concepts: Infection; Safety Reference: Ignatavicius, Workman (2016), pp. 403-404. 152. 3 Rationale: The nurse should suspect the potential for Ebola virus disease (EVD) because of the client’s recent travel to Libe- ria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be F u n d a m e n t a l s 202 UNIT IV Fundamentals of Care
- 221. isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0 °C (100.4 °F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the health care provider and other state and local authorities of the client’s signs and symptoms. Test-Taking Strategy: Note the strategic word, next. This indicates that some or all of the other options may be partially or totally correct, but the nurse needs to prioritize. Eliminate options 1 and 4 first because they are comparable or alike. Next note that the client recently traveled to Liberia. Recall that isolation to prevent transmission of an infection is the immediate priority in the care ofa client with suspected EVD. Review: Care of the client with Ebola virus disease. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Clinical Judgment; Safety Reference: Lewis et al. (2014), p. 228. www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/ emergency-departments.html F u n d a m e n t a l s 203 CHAPTER 16 Provision of a Safe Environment
- 222. F u n d a m e n t a l s CH AP TER 17 Calculation of Medication and Intravenous Prescriptions PRIORITYCONCEPTS Clinical Judgment, Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse is preparing to administer 30 milliliters (mL) of a liquid medication to an assigned client. What should the nurse do when preparing this medication? Answer located on p. 209. I. Medication Administration (Box 17-1) II. Medication Measurement Systems A. Metric system (Box 17-2) 1. The basic units of metric measures are the meter, liter, and gram. 2. Meter measures length; liter measures volume; gram measures mass. B. Apothecary and household systems 1. The apothecary and household systems are the oldest of the medication measurement systems. 2. Apothecary measures such as grain, dram, minim, and ounce are not commonly used in the clinical setting. 3. Commonly used household measures include drop, teaspoon, tablespoon, ounce, pint, and cup. The NCLEX® will not present questions that require you to convert from the apothecary system of measurement to the metric system; however, this system is still important to know because, although it is not common, you may encounter it in the clinical setting. C. Additional common medication measures 1. Milliequivalent a. Milliequivalent is abbreviated mEq. b. The milliequivalent is an expression of the number of grams of a medication contained in 1 mL of a solution. c. For example, the measure of serum potassium is given in milliequivalents. 2. Unit a. Unit measures a medication in terms of its action, not its physical weight. b. For example, penicillin, heparin sodium, and insulin are measured in units. III. Conversions A. Conversion between metric units (Box 17-3) 1. The metric system is a decimal system; therefore, conversions between the units in this system can be done by dividing or multiplying by 1000 or by moving the decimal point 3 places to the right or 3 places to the left. 2. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point 3 places to the right. 3. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal point 3 places to the left. B. Conversion between household and metric systems 1. Household and metric measures are equivalent and not equal measures. 2. Conversion to equivalent measures between systems is necessary when a medication prescrip- tion is written in one system but the medication label is stated in another. 3. Medications are not always prescribed and prepared in the same system of measurement; therefore, conversion of units from one system to another is necessary. However, the metric system is the most commonly used system in the clinical setting. 4. Calculating equivalents between 2 systems may be done by using the method of ratio and pro- portion (Boxes 17-4 and 17-5). Conversion is the first step in the calculation of dosages. 204
- 223. IV. Medication Labels A. Amedication label always contains the generic name and may contain the trade name of the medication. The NCLEXnow onlytests you on generic names of medications. Trade names will not be available for most medications, so be sure to learn medications by their genericnames forthe examination.However,you willlikely still encounter the trade names in the clinical setting. B. Always check expiration dates on medication labels. F u n d a m e n t a l s BOX 17-1 Medication Administration Assess the medication prescription. Compare the client’s medication prescription with all medi- cations that the client was previously taking (medication reconciliation). Ask the client about a history of allergies. Assess the client’s current condition and the purpose for the medication or intravenous (IV) solution. Determine the client’s understanding of the purpose of the prescribed medication or need for IV solution. Teach the client about the medication and about self- administration at home. Identifyand address concerns (social, cultural, religious) that the client may have about taking the medication. Assess the need for conversion when preparing a dose of medication for administration to the client. Assess the 6 rights of medication administration: right med- ication, right dose, right client, right route, right time, and right documentation. Assess the vital signs, check significant laboratory results, and identifyanypotential interactions (food or medication interactions) before administering medication, when appropriate. Document the administration of the prescribed therapy and the client’s response to the therapy. BOX 17-2 Metric System Abbreviations meter: m liter: L milliliter: mL kilogram: kg gram: g milligram: mg microgram: mcg Equivalents 1mcg¼0.000001g 1mg¼1000 mcg or 0.001g 1g¼1000 mg 1kg¼1000 g 1kg¼2.2 lb 1mL¼0.001L BOX 17-3 Conversion Between Metric Units Problem 1 Convert 2 g to milligrams. Solution Change a larger unit to a smaller unit: 2 g¼2000 mg (moving decimal point 3places to the right) Problem 2 Convert 250 mL to liters. Solution Change a smaller unit to a larger unit: 250 mL¼0.25 L(moving decimal point 3places to the left) BOX 17-4 Ratio and Proportion Ratio: The relationship between 2 numbers, separated by a colon; for example, 1:2 (1 to 2). Proportion: The relationship between 2 ratios, separated by a double colon (::) or an equal sign (¼). Formula: H on hand ð Þ: V vehicle ð Þ:: ¼ ð Þ desired dose ð Þ: X unknown ð Þ To solve a ratio and proportion problem: The middle numbers (means) are multiplied and the end numbers (extremes) are multiplied. Sample Problem H ¼1 V¼2 Desired dose¼3 X¼unknown Set up the formula: 1 : 2 :: 3 : X Solve: Multiply means and extremes: 1X¼6 X¼6 BOX 17-5 Calculating Equivalents Between Two Systems Calculating equivalents between 2 systems may be done by using the method of ratio and proportion. Problem The health care provider prescribes nitroglycerin 1 150 grain (gr). The medication label reads 0.4 milligrams (mg) per tablet. The nurse prepares to administer howmanytablets to the client? If you knew that 1 150 gr was equal to 0.4 mg, you would know that you need to administer 1 tablet. Otherwise, use the ratio and proportion formula. Ratio and Proportion Formula H on hand ð Þ: V vehicle ð Þ:: ¼ ð Þ desired dose ð Þ: X unknown ð Þ 1gr : 60 mg :: 1 150 gr : Xmg 60 Â 1 150 ¼ X X ¼ 0:4 mg 1tablet ð Þ 205 CHAPTER 17 Calculation of Medication and Intravenous Prescriptions
- 224. V. Medication Prescriptions (Box 17-6) A. In a medication prescription, the name of the med- ication is written first, followed by the dosage, route, and frequency (depending on the frequency of the prescription, times of administration are usually established by the health care agency and written in an agency policy). B. Medication prescriptions need to be written using accepted abbreviations, acronyms, and symbols approved by The Joint Commission; also follow agency guidelines. If the nurse has any questions about or sees incon- sistencies in the written prescription, the nurse must contact the person who wrote the prescription immedi- ately and must verify the prescription. VI. Oral Medications A. Scored tablets contain an indented mark to be used for possible breakage into partial doses; when neces- sary, scored tablets (those marked for division) can be divided into halves or quarters according to agency policy. B. Enteric-coated tablets and sustained-released cap- sules delay absorption until the medication reaches the small intestine; these medications should not be crushed. C. Capsules contain a powdered or oily medication in a gelatin cover. D. Orally administered liquids are supplied in solution form and contain a specific amount of medication in a given amount of solution, as stated on the label. E. The medicine cup 1. The medicine cup has a capacity of 30 mL or 1 ounce (oz) and is used for orally administered liquids. 2. The medicine cup is calibrated to measure tea- spoons, tablespoons, and ounces. 3. To pour accurately, place the medication cup on a level surface at eye level and then pour the liq- uid while reading the measuring markings. F. Volumes of less than 5 mL are measured using a syringe with the needle removed. A calibrated syringe is used for giving medicine to children. VII. Parenteral Medications A. Parenteral always means an injection route and par- enteral medications are administered by intravenous (IV), intramuscular, subcutaneous, or intradermal injection (see Fig. 17-1 for angles of injection). B. Parenteral medications are packaged in single-use ampules,in single-and multiple-userubber-stoppered vials, and in premeasured syringes and cartridges. C. The nurse should not administer more than 3 mL per intramuscular injection site (2 mL for the deltoid) or 1 mL per subcutaneous injection site; larger volumes are difficult for an injection site to absorb and, if pre- scribed, need to be verified. Variations for pediatric clientsarediscussed in thepediatricsectionsofthistext. D. The standard 3-mL syringe is used to measure most injectable medications and is calibrated in tenths (0.1) of a milliliter. E. The syringe is filled by drawing in solution until the top ring on the plunger (i.e., the ring closest to the needle), not the middle section or the bottom ring of the plunger, is aligned with the desired calibration (Fig. 17-2). F u n d a m e n t a l s BOX 17-6 Medication Prescriptions Name of client Date and time when prescription is written Name of medication to be given Dosage of medication Medication route Time and frequency of administration Signature of person writing the prescription 10 10°–15 –15° 90 90° 90 90° Skin 45° Subcutaneous tissue Muscle Subcutaneous tissue Muscle Epidermis Dermis Skin Bleb Intradermal Intramus cular Subcutaneous 10°–15° 90° 90° FIGURE 17-1 Angles of injection. Tip (Hub) Barrel Read from this point Rubber stopper Plunger FIGURE 17-2 Parts of a syringe. 206 UNIT IV Fundamentals of Care
- 225. Always question and verifyexcessivelylarge or small volumes of medication. F. Prefilled medication cartridge 1. The medication cartridge slips into the cartridge holder, which provides a plunger for injection of the medication. 2. The cartridge is designed to provide sufficient capacity to allow for the addition of a second medication when combined dosages are prescribed. 3. The prefilled medication cartridge is to be used once and discarded; if the nurse is to give less than the full single dose provided, the nurse needs to discard the extra amount before giving the client the injection, in accordance with agency policies and procedures. G. In general, standard medication doses for adults are to be rounded to the nearest tenth (0.1 mL) of a mil- liliter and measured on the milliliter scale; for exam- ple, 1.28 mL is rounded to 1.3 mL (follow agency policy for rounding medication doses). H. When volumes larger than 3 mL are required, the nurse may use a 5-mL syringe; these syringes are cal- ibrated in fifths (0.2 mL) (Fig. 17-3). I. Other syringe sizes may be available (10, 20, and 50 mL) and may be used for medication administra- tion requiring dilution. J. Tuberculin syringe (Fig. 17-4) 1. The tuberculin syringe holds 1 mLand is used to measure small or critical amounts of medication, such as allergen extract, vaccine, or a child’s medication. 2. The syringe is calibrated in hundredths (0.01) of a milliliter, with each one tenth (0.1) marked on the metric scale. K. Insulin syringe (Fig. 17-5) 1. The standard 100-unit insulin syringe is cali- brated for 100 unitsofinsulin (100 units¼1 mL); low-dose insulin syringes (1 2 - and 3 10-mL sizes) may also be used when administering smaller insulin doses. 2. Insulin should not be measured in any other type of syringe. Ifthe insulin prescription states to administer regular and NPH insulin,combinebothtypes ofinsulin inthesame syringe. Use the mnemonic RN: DrawRegular insulin into the insulin syringe first, and then draw the NPH insulin. L. Safety needles contain shielding devices that are attached to the needle and slipped over the needle to reduce the incidence of needle-stick injuries. VIII. Injectable Medications in Powder Form A. Some medications become unstable when stored in solution form and are therefore packaged in powder form. B. Powders must be dissolved with a sterile diluent before use; usually, sterile water or normal saline is used. The dissolving procedure is called reconstitu- tion (Box 17-7). IX. Calculating the Correct Dosage (see Box 17-8 for the standard formula) A. When calculating dosages of oral medications, check the calculation and question the prescription if the calculation calls for more than 3 tablets. F u n d a m e n t a l s 1 2 3 4 5 FIGURE 17-3 Five-milliliter syringe. .10 4m 8m 12m 16m .20 .30 .40 .50 .60 .70 .80 .90 1.0 FIGURE 17-4 Tuberculin syringe. 5 15 25 35 45 55 65 75 85 95 Units 10 20 30 40 50 60 70 80 90 100 FIGURE 17-5 A 100-unit insulin syringe. BOX 17-7 Reconstitution In reconstituting a medication, locate the instructions on the label or in the vial package insert, and read and follow the directions carefully. Instructions will state the volume ofdiluent to be used and the resulting volume of the reconstituted medication. Often, the powdered medication adds volume to the solution in addition to the amount of diluent added. The total volume of the prepared solution will exceed the vol- ume of the diluent added. When reconstituting a multiple-dose vial, label the medication vial with the date and time of preparation, your initials, and the date of expiration. Indicating the strength per volume on the medication label also is important. 207 CHAPTER 17 Calculation of Medication and Intravenous Prescriptions
- 226. F u n d a m e n t a l s B. When calculating dosages of parenteral medications, check the calculation and question the prescription if the amount to be given is too large a dose. C. Be sure that all measures are in the same system, and that all unitsare in the same size, convertingwhen nec- essary;carefully consider what the reasonable amount of the medication that should be administered is. D. Round standard injection doses to tenths and mea- sure in a 3-mL syringe (follow agency policy). E. Round small, critical amounts or children’s doses to hundredths and measure in a 1-mL tuberculin syringe (follow agency policy). F. In addition to using the standard formula (see Box 17-8), calculations can be done using dimen- sional analysis, a method that uses conversion fac- tors to move from one unit of measurement to another; the required elements of the equation include the desired answer units, conversion for- mula that includes the desired answer units and the units that need to be converted, and the original factors to convert including quantity and units. Regardless of the source or cause of a medication error, if the nurse gives an incorrect dose, the nurse is legally responsible for the action. X. Percentage and Ratio Solutions A. Percentage solutions 1. Express the number of grams (g) of the medica- tion per 100 mL of solution. 2. For example, calcium gluconate 10% is 10 g of pure medication per 100 mL of solution. B. Ratio solutions 1. Express the number of grams of the medication per total milliliters of solution. 2. For example, epinephrine 1:1000 is 1 g of pure medication per 1000 mL of solution. XI. Intravenous Flow Rates (Box 17-9) A. Monitor IVflow rate frequentlyeven ifthe IVsolution is being administered through an electronic infusion device (follow agency policy regarding frequency). B. If an IVis running behind schedule, collaborate with the health care provider to determine the client’s ability to tolerate an increased flow rate, particularly for older clients and those with cardiac, pulmonary, renal, or neurological conditions. The nurse should never increase the rate of (i.e., speed up) an IV infusion to catch up if the infusion is running behind schedule. C. Whenever a prescribed IV rate is increased, the nurse should assess the client for increased heart rate, increased respirations, and increased lung congestion, which could indicate fluid overload. D. Intravenously administered fluids are prescribed most frequently based on milliliters per hour to be administered. E. The volume per hour prescribed is administered by setting the flow rate, which is counted in drops per minute. F. Most flow rate calculations involve changing millili- ters per hour to drops per minute. G. Intravenous tubing 1. IV tubing sets are calibrated in drops per millili- ter; this calibration is needed for calculating flow rates. 2. A standard or macrodrip set is used for routine adult IVadministrations; depending on the man- ufacturer and type of tubing, the set will require 10, 15, or 20 drops (gtt) to equal 1 mL. 3. A minidrip or microdrip set is used when more exact measurements are needed, such as in inten- sive care units and pediatric units. 4. In a minidrip or microdrip set, 60 gtt is usually equal to 1 mL. 5. The calibration, in drops per milliliter, is written on the IV tubing package. XII. Calculation of Infusions Prescribed by Unit Dosage per Hour A. Themost common medicationsthat willbeprescribed by unit dosage per hour and run by continuous infu- sion are heparin sodium and regular insulin. BOX 17-8 Standard Formula for Calculating a Medication Dosage D A  Q ¼ X D (desired) is the dosage that the health care provider prescribed. A (available) is the dosage strength as stated on the medica- tion label. Q (quantity) is the volume or form in which the dosage strength is available, such as tablets, capsules, or milliliters. BOX 17-9 Formulas for Intravenous Calculations Flow Rates Totalvolume  Drop factor Time in minutes ¼ Drops per minute Infusion Time Totalvolume to infuse Milliliters per hour being infused ¼ Infusion time Number of Milliliters per Hour Totalvolume in milliliters Number of hours ¼ Number of milliliters per hour 208 UNIT IV Fundamentals of Care
- 227. F u n d a m e n t a l s B. Calculation of these infusions can be done using a 2-step process (Box 17-10). 1. Determine the amount of medication per 1 mL. 2. Determine the infusion rate or milliliters per hour. CRITICALTHINK ING W hat Should Y ou Do? Answer: When preparing to administer a liquid medication, the nurse should use a medicine cup, pouring the liquid into it after placing it on a flat surface at eye level with the thumbnail at the medicine cup line indicating the desired amount. Liquids should not be mixed with tablets or with other liquids in the same container. The nurse should be sure not to return poured medication to its container and should properly discard poured medication if not used. The nurse should pour liquids from the side opposite the bottle’s label to avoid spilling medicine on the label. Medications that irri- tate the gastric mucosa, such as potassium products, should be diluted or taken with meals. Ice chips should be offered before administering unpleasant-tasting medications in order to numb the client’s taste buds. Reference: Perry, Potter, Ostendorf (2014), pp. 486, 496-498. P RAC TI C E Q U ES TI O N S 153. A health care provider’s prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute 154. A health care provider’s prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads pen- icillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place. Answer: _______ mL 155. A health care provider’s prescription reads potas- sium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares BOX 17-10 Infusions Prescribed by Unit Dosage per Hour Calculation ofthese problems can be done using a 2-step process. 1. Determine the amount of medication per 1mL. 2. Determine the infusion rate or milliliters per hour. Problem 1 Prescription: Continuous heparin sodium byIVat 1000 units per hour Available: IV bag of 500 mL D5W with 20,000 units of heparin sodium How manymilliliters per hour are required to administer the correct dose? Solution Step 1: Calculate the amount of medication (units) per milliliter (mL). Known amount of medication in solution Totalvolume of diluent ¼ Amount of medication permilliliter 20,000 units 500 mL ¼ 40 units=1mL Step 2: Calculate milliliters per hour. Dose per hourdesired Concentration per milliliter ¼ Infusion rate, ormL=hour 1000 units 40 units ¼ 25mL=hour Problem 2 Prescription: Continuous regular insulin by IV at 10 units per hour Available: IV bag of 100 mL NS with 50 units regular insulin How manymilliliters per hour are required to administer the correct dose? Solution Step 1: Calculate the amount of medication (units) per milliliter. Known amount of medication in solution Totalvolume of diluent ¼ Amount of medication per milliliter 50 units 100 mL ¼ 0:5units=1mL Step 2: Calculate milliliters per hour. Dose per hour desired Concentration per milliliter ¼ Infusion rate, or mL=hour 10 units 0:5units=mL ¼ 20 mL=hour 209 CHAPTER 17 Calculation of Medication and Intravenous Prescriptions
- 228. F u n d a m e n t a l s how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank. Answer: _______ mL 156. A health care provider’s prescription reads clinda- mycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamy- cin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to admin- ister the correct dose? Fill in the blank. Answer: _______ mL 157. A health care provider’s prescription reads pheny- toin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse pre- pares how many capsule(s) to administer 1 dose? Fill in the blank. Answer: _______ capsule(s) 158. A health care provider prescribes 1000 mL of nor- mal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute 159. A health care provider prescribes heparin sodium, 1300 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mLD5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ mL per hour 160. A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client? Fill in the blank. Answer: _______ mL per hour 161. Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the near- est whole number. Answer: _______ drops per minute 162. A health care provider’s prescription reads levothyroxine, 150 mcg orally daily. The medica- tion label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the cli- ent? Fill in the blank. Answer: _______ tablet(s) 163. Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Answer: _______ drops per minute 164. A health care provider prescribes 1000 mL D5W to infuse at a rate of 125 mL/hour. The nurse deter- mines that it will take how many hours for 1 L to infuse? Fill in the blank. Answer: _______ hour(s) 165. A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute 166. A health care provider’s prescription reads mor- phine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse pre- pares how many milliliters to administer the cor- rect dose? Fill in the blank. Answer: _______ mL 167. A health care provider prescribes regular insulin, 8 units/hour by continuous intravenous (IV) infu- sion. The pharmacy prepares the medication and then delivers an IVbag labeled 100 units of regular insulin in 100 mLnormal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour? Fill in the blank. Answer: _______ mL/hour 210 UNIT IV Fundamentals of Care
- 229. AN S WERS : ALTERN ATE I TEM F O RM AT ( F I LL-I N -TH E-BLAN K) 153. 21 Rationale: Use the intravenous (IV) flow rate formula. Formula: Total Volume  Drop factor Time in minutes ¼ Drops per minute 1000 mL 15 gtt 720 minutes ¼ 15,000 720 ¼ 20:8, or 21 gtt=min Test-Taking Strategy: Focuson thesubject,IVflowrates.Usethe formulaforcalculatingIVflowrateswhen answeringthequestion. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 154. 1.3 Rationale: Use the medication dose formula. Formula: Desired  mL Available ¼ Milliliters per dose 400,000 units 1 mL 300,000 units ¼ Milliliters per dose 400,000 300,000 ¼ 1:33 ¼ 1:3 mL Test-Taking Strategy: Focuson thesubject,a dosagecalculation. Follow the formula for the calculation of the correct medication dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to record your answer using 1 decimal place. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 155. 15 Rationale: In most facilities, potassium chloride is premixed in the intravenous solution and the nurse will need to verify the correct dose before administration. In some cases the nurse will need to add the potassium chloride and will use the medica- tion calculation formula to determine the mL to be added. Formula: Desired  mL Available ¼ Milliliters per dose 30 mEq  20 mL 40 mEq ¼ 15 mL Test-Taking Strategy: Focus on the subject, a dosage calcula- tion. Follow the formula for the calculation of the correct med- ication dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamental of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 156. 2 Rationale: You must convert 0.3 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 0.3 g¼300 mg. Following conversion from grams to milligrams, use the for- mula to calculate the correct dose. Formula: Desired  mL Available ¼ Milliliters per dose 300 mg 6 mL 900 mg ¼ 1800 900 ¼ 2 mL Test-Taking Strategy: Focus on the subject, a dosage calcula- tion. In this medication calculation problem, first you must convert grams to milligrams. Once you have performed the cal- culation, verify your answer using a calculator and make sure that the answer makes sense. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 157. 2 Rationale: You must convert 0.2 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point 3 places to the right. Therefore, 0.2 g equals 200 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose. Formula: Desired  Capsule s ð Þ Available ¼ Capsule s ð Þper dose 200 mg 1 Capsule 100 mg ¼ 2 Capsules Test-Taking Strategy: Focus on the subject, a dosage calcula- tion. In this medication calculation problem, first you must convert grams to milligrams. Once you have done the conversion and reread the medication calculation problem, you will know that 2 capsules is the correct answer. Recheck F u n d a m e n t a l s 211 CHAPTER 17 Calculation of Medication and Intravenous Prescriptions
- 230. your work using a calculator and make sure that the answer makes sense. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 158. 31 Rationale: Use the intravenous (IV) flow rate formula. Formula: Total volume Drop factor Time in Minutes ¼ Drop per minute 1000 mL 15 gtt 480 minutes ¼ 15,000 480 ¼ 31:2, or 31 gtt=min Test-Taking Strategy: Focus on the subject, an IV flow rate. Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 159. 16 Rationale: Calculation of this problem can be done using a 2- step process. First, you need to determine the amount of hep- arin sodium in 1 mL. The next step is to determine the infusion rate, or milliliters per hour. Step 1: Known amount of medication in solution Total volume of diluent ¼ Amount of medication per millimeter 20,000 units 250 mL ¼ 80 units=mL Step 2: Dose per hour desired Concentration per millileter ¼ Infusion rate, or mL=hr 1300 units 80 units=mL ¼ 16:25, or 16 mL=hr Test-Taking Strategy: Focus on the subject, an IV flow rate. Read the question carefully, noting that 2 steps can be used to solve this medication problem. Follow the formula, verify your answer using a calculator, and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review: Intravenous infusion calculations Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 160. 125 Rationale: Use the intravenous (IV) formula to determine mil- liliters per hour. Formula: Total volume in milliliters Number of hours ¼ Milliliters per hour 3000 mL 24 hours ¼ 125 mL=hr Test-Taking Strategy: Focus on the subject, an IVinfusion cal- culation. Read the question carefully, noting that the question is asking about milliliters per hour to be administered to the client. Use the formula for calculating milliliters per hour. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 161. 33 Rationale: Use the intravenous (IV) flow rate formula. Formula: Total volume  Drop factor Time in minutes ¼ Drops per minute 100 mL 10 gtt 30 minutes ¼ 1000 30 ¼ 33:3, or 33 gtt=min Test-Taking Strategy: Focus on the subject, an IVinfusion cal- culation. Use the formula for calculating IV flow rates when answering the question. Once you have performed the calcula- tion, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 162. 1.5 Rationale: You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or F u n d a m e n t a l s 212 UNIT IV Fundamentals of Care
- 231. move the decimal 3 places to the left. Therefore, 150 mcg equals 0.15 mg. Next, use the formula to calculate the correct dose. Formula: Desired Available  Tablet ¼ Tabletsper dose 0:15 mg 0:1 mg  1 tablet ¼ 1:5 tablets Test-Taking Strategy: Focus on the subject, a dosage calcula- tion. In this medication calculation problem, first you must convert micrograms to milligrams. Next, follow the formula for the calculation of the correct dose, verify your answer using a calculator, and make sure that the answer makes sense. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 163. 25 Rationale: Use the intravenous (IV) flow rate formula. Formula: Total volume Drop factor Time in minutes ¼ Drops per minute 50 mL 15 gtt 30 minutes ¼ 750 30 ¼ 25 gtt=min Test-Taking Strategy: Focus on the subject, an IVinfusion cal- culation. Use the formula for calculating IV flow rates when answering the question. Once you have performed the calcula- tion, verify your answer using a calculator and make sure that the answer makes sense. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 164. 8 Rationale: You must determine that 1 Lequals 1000 mL. Next, use the formula for determining infusion time in hours. Formula: Total volume to infuse Milliliters per hour being infused ¼ Infusion time 1000 mL 125 mL ¼ 8 hours Test-Taking Strategy: Focus on the subject, an intravenous infusion calculation. Read the question carefully, noting that the question is asking about infusion time in hours. First, con- vert 1 L to milliliters. Next, use the formula for determining infusion time in hours. Verify your answer using a calculator and make sure that the answer makes sense. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety References: Perry, Potter, Ostendorf (2014), pp. 710-711. 165. 10 Rationale: Use the intravenous (IV) flow rate formula. Formula: Total volume  Drop factor Time in minute ¼ Drops per minute 250 mL  10 gtt 240 minutes ¼ 2500 240 ¼ 10:4, or 10 gtt=min Test-Taking Strategy: Focus on the subject, an IVinfusion cal- culation. Use the formula for calculating IV flow rates when answering the question. Once you have performed the calcula- tion, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review: Intravenous infusion calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 710-711. 166. 0.8 Rationale: Use the formula to calculate the correct dose. Formula: Desired  mL Available ¼ Millilitersper hour 8 mg 1 mL 10 mg ¼ 0:8 mL Test-Taking Strategy: Focus on the subject, a dosage calcula- tion. Follow the formula for the calculation of the correct dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Review: Medication calculations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 486-487. 167. 8 Rationale: Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of F u n d a m e n t a l s 213 CHAPTER 17 Calculation of Medication and Intravenous Prescriptions
- 232. regular insulin in 1 mL. The next step is to determine the infu- sion rate, or milliliters per hour. Formula: Step 1: Known amount of medication in solution Total volume of diluent ¼ Amount of medication per milliliter 100 units 100 mL ¼ 1 unit=mL Step 2: Dose per hour desired Concentration per milliliter ¼ Infusion rate, or millilitersper hour 8 units 1 unit=mL ¼ 8 mL=hour Test-Taking Strategy: Focus on the subject, an IV flow rate. Read the question carefully, noting that 2 steps can be used to solve this medication problem. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. These steps can be used for similar medication problems related to the administration of heparin sodium or regular insulin by IV infusion. Review: Medication calculations Level of Cognitive Ability: Analyzing Client Need: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Medications/IV Calculations Priority Concepts: Clinical Judgment; Safety References: Perry, Potter, Ostendorf (2014), pp. 486-487. F u n d a m e n t a l s 214 UNIT IV Fundamentals of Care
- 233. F u n d a m e n t a l s CH AP TER 18 Perioperative Nursing Care PRIORITYCONCEPT Infection; Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse is assisting the surgeon in obtaining informed con- sent from a client for a scheduled surgical procedure. The cli- ent signs the consent and after the surgeon leaves the nursing unit the client informs the nurse that he is unclear about certain aspects of the surgical procedure. What should the nurse do? Answer located on p. 225. I. Preoperative Care Aclient may return home shortly after having a sur- gical procedure because many surgical procedures are done through ambulatorycare or 1-daystaysurgicalunits. Perioperative care procedures apply even when the client returns home on the same day of the surgical procedure. A. Obtaining informed consent 1. The surgeon is responsible for explaining the sur- gical procedure to the client and answering the client’s questions. Often, the nurse is responsible for obtaining the client’s signature on the con- sent form for surgery, which indicates the client’s agreement to the procedure based on the surgeon’s explanation. 2. The nurse may witness the client’s signing of the consent form, but the nurse must be sure that the client has understood the surgeon’s explanation of the surgery. 3. The nurse needs to document the witnessing of the signing of the consent form after the client acknowledges understanding the procedure. 4. Minors (clients younger than 18 years) may need a parent or legal guardian to sign the consent form. 5. Older clients may need a legal guardian to sign the consent form. 6. Psychiatric clients have a right to refuse treatment until a court has legally determined that they are unable to make decisions for themselves. 7. No sedation should be administered to the client before the client signs the consent form. 8. Obtaining telephone consent from a legal guard- ian or power of attorney for health care is an acceptable practice if clients are unable to give consent themselves. The nurse must engage another nurse as a witness to the consent given over the telephone. B. Nutrition 1. Review the surgeon’s prescriptions regarding the NPO (nothing by mouth) status before surgery. 2. Withhold solid foods and liquids as prescribed to avoid aspiration, usually for 6 to 8 hours before general anesthesia and for approximately 3 hours before surgery with local anesthesia (as prescribed). 3. Insert an intravenous (IV) line and administer IV fluids, if prescribed; per agency policy, the IV catheter size should be large enough to adminis- ter blood products if they are required. C. Elimination 1. If the client is to have intestinal or abdominal surgery, per surgeon’s preference an enema, lax- ative, or both may be prescribed for the day or night before surgery. 2. The client should void immediately before surgery. 3. Insert an indwelling urinary catheter, if pre- scribed; urinary catheter collection bags should be emptied immediately before surgery, and the nurse should document the amount and characteristics of the urine. D. Surgical site 1. Clean the surgical site with a mild antiseptic or antibacterial soap on the night before surgery, as prescribed. 2. Shave the operative site, as prescribed; shaving may be done in the operative area. 215
- 234. Hair on the head or face (including the eyebrows) should be shaved only if prescribed. E. Preoperative client teaching 1. Inform the client about what to expect postoperatively. 2. Inform the client to notify the nurse if the client experiences any pain postoperatively and that pain medication will be prescribed and given as the client requests. The client should be informed that some degree of pain should be expected and is normal. 3. Inform the client that requesting an opioid after surgery will not make the client a drug addict. 4. Demonstrate the use of a patient-controlled anal- gesia (PCA) pump if prescribed. 5. Instruct the client how to use noninvasive pain- relief techniques such as relaxation, distraction techniques, and guided imagery before the pain occurs and as soon as the pain is noticed. 6. The nurse should instruct the client not to smoke (for at least 24 hours before surgery); discuss smoking cessation treatments and programs. 7. Instruct the client in deep-breathing and cough- ing techniques, use of incentive spirometry, and the importance of performing the techniques postoperatively to prevent the development of pneumonia and atelectasis (Box 18-1). 8. Instruct the client in leg and foot exercises to pre- vent venous stasis of blood and to facilitate venous blood return (Fig. 18-1; see Box 18-1). 9. Instruct the client in how to splint an incision, turn, and reposition (Fig. 18-2; see Box 18-1). 10. Inform the client of any invasive devices that may be needed after surgery, such as a nasogastric tube, drain, urinary catheter, epidural catheter, or IV or subclavian lines. 11. Instruct the client not to pull on any of the inva- sive devices; they will be removed as soon as possible. F. Psychosocial preparation 1. Be alert to the client’s level of anxiety. 2. Answer any questions or concerns that the client may have regarding surgery. 3. Allow time for privacy for the client to prepare psychologically for surgery. 4. Provide support and assistance as needed. 5. Take cultural aspects into consideration when providing care (Box 18-2). G. Preoperative checklist 1. Ensure that the client is wearing an identification bracelet. 2. Assess for allergies, including an allergy to latex (see Chapter 66 for information on latex allergy). 3. Review the preoperative checklist to be sure that each item is addressed before the client is trans- ported to surgery. 4. Follow agency policies regarding preoperative procedures, including informed consents, preop- erative checklists, prescribed laboratory or radio- logical tests, and any other preoperative procedure. 5. Ensure that informed consent forms have been signed for the operative procedure, any blood transfusions, disposal of a limb, or surgical ster- ilization procedures. 6. Ensure that a history and physical examination have been completed and documented in the cli- ent’s record (Box 18-3). 7. Ensure that consultation requests have been completed and documented in the client’s record. F u n d a m e n t a l s BOX 18-1 Client Teaching Deep-Breathing and Coughing Exercises Instruct the client that a sitting position gives the best lung expansion for coughing and deep-breathing exercises. Instruct the client to breathe deeply 3 times, inhaling through the nostrils and exhaling slowly through pursed lips. Instruct the client that the third breath should be held for 3sec- onds; then the client should cough deeply 3 times. The client should perform this exercise every 1 to 2 hours. Incentive Spirometry Instruct the client to assume a sitting or upright position. Instruct the client to place the mouth tightly around the mouthpiece. Instruct the client to inhale slowly to raise and maintain the flow rate indicator, usually between the 600 and 900 marks on the device. Instruct the client to hold the breath for 5seconds and then to exhale through pursed lips. Instruct the client to repeat this process 10 times every hour. Leg and Foot Exercises Gastrocnemius (calf) pumping: Instruct the client to move both ankles by pointing the toes up and then down. Quadriceps (thigh) setting: Instruct the client to press the back of the knees against the bed and then to relax the knees; this contracts and relaxes the thigh and calfmuscles to prevent thrombus formation. Foot circles: Instruct the client to rotate each foot in a circle. Hip and knee movements: Instruct the client to flex the knee and thigh and to straighten the leg, holding the position for 5 seconds before lowering (not performed if the client is having abdominal surgery or if the client has a back problem). Splinting the Incision If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or 1 hand with the other hand on top, over the incisional area. During deep breathing and coughing, the client presses gently against the incisional area to splint or support it. 216 UNIT IV Fundamentals of Care
- 235. 8. Ensure that prescribed laboratory results are documented in the client’s record. 9. Ensure that electrocardiogram and chest radiog- raphy reports are documented in the client’s record. 10. Ensure that a blood type, screen, and crossmatch are performed and documented in the client’s record within the established time frame per agency policy. 11. Remove jewelry, makeup, dentures, hairpins, nail polish (depending on agency procedures), glasses, and prostheses. F u n d a m e n t a l s Gastrocnemius (calf) pumping Quadriceps (thigh) setting Hip and knee movements Foot circles Des irable Es s ential FIGURE 18-1 Postoperative leg exercises. FIGURE 18-2 Techniques for splinting a wound when coughing. BOX 18-2 Cultural Aspects of Perioperative Nursing Care Cultural assessment includes questions related to: ▪ Primary language spoken ▪ Feelings related to surgery and pain ▪ Pain management ▪ Expectations ▪ Support systems ▪ Feelings toward self ▪ Cultural practices and beliefs Allow a family member to be present if appropriate. Secure the help of a professional interpreter to communicate with non–English-speaking clients. Use pictures or phrase cards to communicate and assess the non–English-speaking client’s perception of pain or other feelings. Provide preoperative and postoperative educational materials in the appropriate language. Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. BOX18-3 Medical Conditions That Increase Risk During Surgery ▪ Bleeding disorders such as thrombocytopenia or hemophilia ▪ Diabetes mellitus ▪ Chronic pain ▪ Heart disease, such as a recent myocardial infarction, dys- rhythmia, heart failure, or peripheral vascular disease ▪ Obstructive sleep apnea ▪ Upper respiratory infection ▪ Liver disease ▪ Fever ▪ Chronic respiratorydisease, such as emphysema, bronchi- tis, or asthma ▪ Immunological disorders, such as leukemia, infection with human immunodeficiency virus, acquired immunodefi- ciency syndrome, bone marrow depression, or use of chemotherapy or immunosuppressive agents ▪ Abuse of street drugs Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 217 CHAPTER 18 Perioperative Nursing Care
- 236. 12. Document that valuables have been given to the client’s family members or locked in the hospital safe. 13. Document the last time that the client ate or drank. 14. Document that the client voided before surgery. 15. Document that the prescribed preoperative med- ications were given (Box 18-4). 16. Monitor and document the client’s vital signs. H. Preoperative medications 1. Prepare to administer preoperative medications as prescribed before surgery. 2. Instruct the client about the desired effects of the preoperative medication. After administering the preoperative medications, keep the client in bed with the side rails up (per agencypol- icy). Place the call bell next to the client; instruct the client not to get out of bed and to call for assistance if needed. I. Arrival in the operating room 1. Guidelines to prevent wrong site and wrong pro- cedure surgery a. The surgeon meets with the client in the pre- operative area and uses indelible ink to mark the operative site. b. In the operating room, the nurse and surgeon ensure and reconfirm that the operative site has been appropriately marked. c. Just before starting the surgical procedure, a time-out is conducted with all members of the operative team present to identify the correct client and appropriate surgical site again. 2. When the client arrives in the operating room, the operating room nurse will verify the identifi- cation bracelet with the client’s verbal response and will review the client’s chart. 3. The client’s record will be checked for complete- ness and reviewed for informed consent forms, history and physical examination, and allergic reaction information. 4. The surgeon’s prescriptions will be verified and implemented. 5. The IVline may be initiated at this time (or in the preoperative area), if prescribed. 6. The anesthesia team will administer the pre- scribed anesthesia. Verification of the client and the surgical operative site is critical. F u n d a m e n t a l s BOX 18-4 Substances That Can Affect the Client in Surgery Antibiotics Antibiotics potentiate the action of anesthetic agents. Anticholinergics Medications with anticholinergic effects increase the potential for confusion, tachycardia, and intestinal hypotonicity and hypomotility. Anticoagulants, antiplatelets, and thrombolytics These medications alter normal clotting factors and increase the risk of hemorrhaging. Acetylsalicylic acid (Aspirin), clopidogrel, and nonsteroidal anti- inflammatory drugs are commonly used medications that can alter platelet aggregation. These medications should be discontinued at least 48 hours before surgery or as specified by the surgeon; clopidogrel usually has to be discontinued 5 days before surgery. Anticonvulsants Long-term use of certain anticonvulsants can alter the metabo- lism of anesthetic agents. Antidepressants Antidepressants maylower the blood pressure during anesthesia. Antidysrhythmics Antidysrhythmic medications reduce cardiac contractility and impair cardiac conduction during anesthesia. Antihypertensives Antihypertensive medications can interact with anesthetic agents and cause bradycardia, hypotension, and impaired circulation. Corticosteroids Corticosteroids cause adrenal atrophy and reduce the ability of the body to withstand stress. Before and during surgery, dosages may be increased temporarily. Diuretics Diuretics potentiate electrolyte imbalances after surgery. Herbal Substances Herbal substances can interact with anesthesia and cause a variety of adverse effects. These substances may need to be stopped at a specific time before surgery. During the pre- operative period, the client needs to be asked if he or she is taking an herbal substance. Insulin The need for insulin after surgery in a diabetic may be reduced because the client’s nutritional intake is decreased, or the need for insulin may be increased because of the stress response and intravenous administration of glucose solutions. Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 218 UNIT IV Fundamentals of Care
- 237. F u n d a m e n t a l s II. Postoperative Care A. Description 1. Postoperative care is the management of a client after surgery and includes care given during the immediate postoperative period as well as during the days following surgery. 2. The goal of postoperative care is to prevent com- plications, to promote healing of the surgical inci- sion, and to return the client to a healthy state. B. Respiratory system Assess breath sounds; stridor, wheezing, or a crow- ing sound can indicate partial obstruction, broncho- spasm, or laryngospasm, while crackles or rhonchi may indicate pulmonary edema. 1. Monitor vital signs. 2. Monitor airway patency and ensure adequate ventilation (prolonged mechanical ventilation during anesthesia may affect postoperative lung function). 3. Remember that extubated clients who are lethar- gic may not be able to maintain an airway. 4. Monitor for secretions; if the client is unable to clear the airway by coughing, suction the secre- tions from the client’s airway. 5. Observe chest movement for symmetry and the use of accessory muscles. 6. Monitor oxygen administration if prescribed. 7. Monitor pulse oximetry and end title carbon dioxide (CO2) as prescribed. 8. Encourage deep-breathing and coughing exer- cises as soon as possible after surgery. 9. Note the rate, depth, and quality of respirations; the respiratory rate should be greater than 10 and less than 30 breaths/minute. 10. Monitor for signs of respiratory distress, atelecta- sis, or other respiratory complications. C. Cardiovascular system 1. Monitor circulatory status, such as skin color, peripheral pulses, and capillary refill, and for the absence of edema, numbness, and tingling. 2. Monitor for bleeding. 3. Assess the pulse for rate and rhythm (a bounding pulse may indicate hypertension, fluid overload, or client anxiety). 4. Monitor for signs of hypertension and hypotension. 5. Monitor for cardiac dysrhythmias. 6. Monitor for signs of thrombophlebitis, particu- larly in clients who were in the lithotomy posi- tion during surgery. 7. Encourage the use of antiembolism stockings or sequential compression devices (Fig. 18-3), if prescribed, to promote venous return, strengthen muscle tone, and prevent pooling of blood in the extremities. D. Musculoskeletal system 1. Assess the client for movement of the extremities. 2. Review the surgeon’s prescriptions regarding cli- ent positioning or restrictions. 3. Encourage ambulation if prescribed; before ambulation, instruct the client to sit at the edge of the bed with his or her feet supported to assume balance. 4. Unless contraindicated, place the client in a low Fowler’s position after surgery to increase the size of the thorax for lung expansion. 5. Avoid positioning the postoperative client in a supine position until pharyngeal reflexes have returned; if the client is comatose or semicoma- tose, position on the side (in addition, an oral airway may be needed). 6. If the client is unable to get out of bed, turn the client every 1 to 2 hours. E. Neurological system 1. Assess level of consciousness. 2. Make frequent periodic attempts to awaken the client until the client awakens. 3. Orient the client to the environment. 4. Speak in a soft tone; filter out extraneous noises in the environment. 5. Maintain the client’s body temperature and pre- vent heat loss by providing the client with warm blankets and raising the room temperature as necessary. F. Temperature control 1. Monitor temperature. 2. Monitor for signs of hypothermia that may result from anesthesia, a cool operating room, or expo- sure of the skin and internal organs during surgery. 3. Apply warm blankets, continue oxygen, and administer medication as prescribed if the client experiences postoperative shivering. G. Integumentary system 1. Assess the surgical site, drains, and wound dress- ings (serous drainage may occur from an inci- sion, but notify the surgeon if excessive bleeding occurs from the site). 2. Assess the skin for redness, abrasions, or break- down that may have resulted from surgical positioning. FIGURE 18-3 Sequential compression device. 219 CHAPTER 18 Perioperative Nursing Care
- 238. 3. Monitor body temperature and wound for signs of infection. 4. Maintain a dry, intact dressing. 5. Change dressings as prescribed, noting the amount of bleeding or drainage, odor, and intact- ness of sutures or staples; commonly used dress- ings include 4 Â 4 inch gauze, nonadherent pads, abdominal pads, gauze rolls, and split gauze that are commonly referred to as drain sponges. 6. Wound drains should be patent; prepare to assist with the removal of drains (as prescribed by the surgeon) when the drainage amount becomes insignificant. 7. An abdominal binder may be prescribed for obese and debilitated individuals to prevent dehiscence of the incision. H. Fluid and electrolyte balance 1. Monitor IV fluid administration as prescribed. 2. Record intake and output. 3. Monitor for signs of fluid or electrolyte imbal- ances. I. Gastrointestinal system 1. Monitor intake and output and for nausea and vomiting. 2. Maintain patency of the nasogastric tube if pre- sent and monitor placement and drainage per agency procedure. 3. Monitor for abdominal distention. 4. Monitor for passage of flatus and return of bowel sounds. 5. Administer frequent oral care, at least every 2 hours. 6. Maintain the NPO status until the gag reflex and peristalsis return. 7. When oral fluids are permitted, start with ice chips and water. 8. Ensure that the client advances to clear liquids and then to a regular diet, as prescribed and as the client can tolerate. To prevent aspiration, turn the client to a side-lying position if vomiting occurs; have suctioning equipment available and ready to use. J. Renal system 1. Assess the bladder for distention. 2. Monitor urine output (urinary output should be at least 30 mL/hour). 3. If the client does not have a urinary catheter, the client is expected to void within 6 to 8 hours postoperatively depending on the type of anes- thesia administered; ensure that the amount is at least 200 mL. K. Pain management 1. Assess the type of anesthetic used and preopera- tive medication that the client received, and note whether the client received any pain medications in the postanesthesia period. 2. Assess for pain and inquire about the type and location of pain; ask the client to rate the degree of pain on a scale of 1 to 10, with 10 being the most severe. 3. If the client is unable to rate the pain using a numerical pain scale, use a descriptor scale that lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain, or other available pain rat- ing scales. 4. Monitor for objective data related to pain, such as facial expressions, body gestures, increased pulse rate, increased blood pressure, and increased respirations. 5. Inquire about the effectiveness of the last pain medication. 6. Administer pain medication as prescribed. 7. Ensure that the client with a PCA pump under- stands how to use it. 8. If an opioid has been prescribed, after adminis- tration assess the client every 30 minutes for respiratory rate and pain relief. 9. Use noninvasive measures to relieve postopera- tive pain, including provision of distraction, relaxation techniques, guided imagery, comfort measures, positioning, backrubs, and a quiet and restful environment. 10. Document effectiveness of the pain medication and noninvasive pain-relief measures. Consider cultural practices and beliefs when plan- ning pain management. III. Pneumonia and Atelectasis A. Description (Box 18-5 and Fig. 18-4) 1. Pneumonia: An inflammation of the alveoli caused by an infectious process that may develop 3 to 5 days postoperatively as a result of infec- tion, aspiration, or immobility 2. Atelectasis: Acollapsed or airless state of the lung that may be the result of airway obstruction F u n d a m e n t a l s BOX 18-5 Postoperative Complications ▪ Pneumonia and atelectasis ▪ Hypoxemia ▪ Pulmonary embolism ▪ Hemorrhage ▪ Shock ▪ Thrombophlebitis ▪ Urinary retention ▪ Constipation ▪ Paralytic ileus ▪ Wound infection ▪ Wound dehiscence ▪ Wound evisceration 220 UNIT IV Fundamentals of Care
- 239. F u n d a m e n t a l s caused by accumulated secretions or failure of the client to deep-breathe or ambulate after sur- gery; a postoperative complication that usually occurs 1 to 2 days after surgery B. Assessment 1. Dyspnea and increased respiratory rate 2. Crackles over involved lung area 3. Elevated temperature 4. Productive cough and chest pain C. Interventions 1. Assess lung sounds. 2. Reposition the client every 1 to 2 hours. 3. Encourage the client to deep-breathe, cough, and use the incentive spirometer as prescribed. 4. Provide chest physiotherapy and postural drain- age, as prescribed. 5. Encourage fluid intake and early ambulation. 6. Use suction to clear secretions if the client is unable to cough. IV. Hypoxemia A. Description: An inadequate concentration of oxygen in arterial blood; in the postoperative client, hypox- emia can be due to shallow breathing from the effects of anesthesia or medications. B. Assessment 1. Restlessness 2. Dyspnea 3. Diaphoresis 4. Tachycardia 5. Hypertension 6. Cyanosis 7. Low pulse oximetry readings C. Interventions 1. Monitor for signs of hypoxemia. 2. Notify the surgeon. 3. Monitor lung sounds and pulse oximetry. 4. Administer oxygen as prescribed. 5. Encourage deep breathing and coughing and use of the incentive spirometer. 6. Turn and reposition the client frequently; encourage ambulation. V. Pulmonary Embolism A. Description: An embolus blocking the pulmonary artery and disrupting blood flow to 1 or more lobes of the lung B. Assessment 1. Sudden dyspnea 2. Sudden sharp chest or upper abdominal pain 3. Cyanosis 4. Tachycardia 5. A drop in blood pressure C. Interventions 1. Notify the surgeon immediately because pulmo- nary embolism may be life-threatening and requires emergency action. 2. Monitor vital signs. 3. Administer oxygen and medications as prescribed. VI. Hemorrhage A. Description: The loss of a large amount of blood externally or internally in a short time period B. Assessment 1. Restlessness 2. Weak and rapid pulse 3. Hypotension 4. Tachypnea 5. Cool, clammy skin 6. Reduced urine output C. Interventions 1. Provide pressure to the site of bleeding. 2. Notify the surgeon. 3. Administer oxygen, as prescribed. 4. Administer IV fluids and blood, as prescribed. 5. Prepare the client for a surgical procedure, if necessary. VII. Shock A. Description: Loss of circulatory fluid volume, which usually is caused by hemorrhage B. Assessment: Similar to assessment findings in hemorrhage C. Interventions 1. If shock develops, elevate the legs. 2. Notify the surgeon. 3. Determine and treat the cause of shock. 4. Administer oxygen, as prescribed. 5. Monitor level of consciousness. Alveoli lined by flattened epithelium to allow gas exchange Mucous plug A B C Mucous plugs accumulating Air absorbed from alveoli; lung segment collapses FIGURE 18-4 Postoperative atelectasis. A, Normal bronchiole and alveoli. B, Mucous plug in bronchiole. C, Collapse of alveoli caused by atelectasis following absorption of air. 221 CHAPTER 18 Perioperative Nursing Care
- 240. 6. Monitor vital signs for increased pulse or decreased blood pressure. 7. Monitor intake and output. 8. Assess color, temperature, turgor, and moisture of the skin and mucous membranes. 9. Administer IV fluids, blood, and colloid solu- tions, as prescribed. Ifthe client had spinal anesthesia, do not elevate the legs any higher than placing them on the pillow; other- wise, the diaphragm muscles needed for effective breathing could be impaired. VIII. Thrombophlebitis A. Description 1. Thrombophlebitis is an inflammation of a vein, often accompanied by clot formation. 2. Veins in the legs are affected most commonly. B. Assessment 1. Vein inflammation 2. Aching or cramping pain 3. Vein feels hard and cordlike and is tender to touch. 4. Elevated temperature C. Interventions 1. Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis; notify the surgeon if any of these signs are present. 2. Elevate the extremity 30 degrees without allow- ing any pressure on the popliteal area. 3. Encourage the use of antiembolism stockings as prescribed; remove stockings twice a day to wash and inspect the legs. 4. Use a sequential compression device as pre- scribed (see Fig. 18-3). 5. Perform passive range-of-motion exercises every 2 hours if the client is confined to bed rest. 6. Encourage early ambulation, as prescribed. 7. Do not allow the client to dangle the legs. 8. Instruct the client not to sit in 1 position for an extended period of time. 9. Administer anticoagulants such as heparin sodium or enoxaparin, as prescribed. IX. Urinary Retention A. Description 1. Urinary retention is an involuntary accumula- tion of urine in the bladder as a result of loss of muscle tone. 2. It is caused by the effects of anesthetics or opioid analgesics and appears 6 to 8 hours after surgery. B. Assessment 1. Inability to void 2. Restlessness and diaphoresis 3. Lower abdominal pain 4. Distended bladder 5. Hypertension 6. On percussion, bladder sounds like a drum. C. Interventions 1. Monitor for voiding. 2. Assess for a distended bladder by palpation and bladder scanning if indicated. 3. Encourage ambulation when prescribed. 4. Encourage fluid intake unless contraindicated. 5. Assist the client to void by helping the client to stand. 6. Provide privacy. 7. Pour warm water over the perineum or allow the client to hear running water to promote voiding. 8. Contact the surgeon and catheterize the client as prescribed after all noninvasive techniques have been attempted. X. Constipation A. Description 1. Constipation is an abnormal infrequent passage of stool. 2. When the client resumes a solid diet postopera- tively, failure to pass stool within 48 hours may indicate constipation. B. Assessment 1. Absence of bowel movements 2. Abdominal distention 3. Anorexia, headache, and nausea C. Interventions 1. Assess bowel sounds. 2. Encourage fluid intake up to 3000 mL/day unless contraindicated. 3. Encourage early ambulation. 4. Encourage consumption of fiber foods unless contraindicated. 5. Provide privacy and adequate time for bowel elimination. 6. Administer stool softeners and laxatives, as prescribed. XI. Paralytic Ileus A. Description 1. Paralytic ileus is failure of appropriate forward movement of bowel contents. 2. The condition may occur as a result of anesthetic medications or of manipulation of the bowel during the surgical procedure. B. Assessment 1. Vomiting postoperatively 2. Abdominal distention 3. Absence of bowel sounds, bowel movement, or flatus C. Interventions 1. Monitor intake and output. 2. Maintain NPO status until bowel sounds return. 3. Maintain patency of a nasogastric tube if in place; assess patency and drainage per agency procedure. 4. Encourage ambulation. F u n d a m e n t a l s 222 UNIT IV Fundamentals of Care
- 241. F u n d a m e n t a l s 5. Administer IV fluids or parenteral nutrition, as prescribed. 6. Administer medications as prescribed to increase gastrointestinal motility and secretions. 7. If ileus occurs, it is treated first nonsurgically with bowel decompression by insertion of a nasogas- tric tube attached to intermittent or constant suction. Vomiting postoperatively, abdominal distention, and absence of bowel sounds may be signs of paralytic ileus. XII. Wound Infection A. Description 1. Wound infection may be caused by poor aseptic technique or a contaminated wound before sur- gical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk. 2. Infection usually occurs 3 to 6 days after surgery. 3. Purulent material may exit from the drains or separated wound edges. B. Assessment 1. Fever and chills 2. Warm, tender, painful, and inflamed incision site 3. Edematous skin at the incision and tight skin sutures 4. Elevated white blood cell count C. Interventions 1. Monitor temperature. 2. Monitor incision site for approximation of suture line, edema, or bleeding, and signs of infection (REEDA: redness, erythema, ecchymo- sis, drainage, approximation of the wound edges); notify the surgeon if signs of wound infection are present. 3. Maintain patency of drains, and assess drainage amount, color, and consistency. 4. Maintain asepsis, change the dressing, and per- form wound irrigation, if prescribed (Box 18-6). 5. Administer antibiotics, as prescribed. BOX 18-6 Procedure for Sterile Dressing Change and Wound Irrigation* Verify the prescription for the procedure in the medical record. Anticipate supplies that will be needed and gather supplies, including personal protective equipment (PPE) and addi- tional equipment needed for protection (i.e., gown, face shield, clean gloves), a sterile dressing change kit if avail- able, and any anticipated additional supplies such as gauze pads, drain sponges, cotton tipped applicators, tape, an abdominal pad, a measuring tool, syringe for irrigation, irri- gation basin, extra pair of sterile gloves, and underpad. Introduce self to client, identify the client with 2 accepted iden- tifiers and compare against medical record, provide privacy, and explain the procedure. Assess the client’s pain level using an appropriate pain scale and medicate as necessary. Assess the client for allergies, particularly to tape or latex. Perform hand hygiene and don PPE. Position the client appropriately, apply clean gloves, and place the underpad underneath the client. Remove the soiled dressing, assess and characterize drainage noted on the dressing, and discard the removed dressing in the biohazard waste; note: if a moist-to-dry dressing adheres to the wound, gently free the dressing and warn the client of the discomfort; if a dry dressing adheres to the wound that is not to be debrided, moisten the dressing with normal saline and remove. Assess the wound and periwound for size (length, width, depth; measure using measuring tool), appearance, color, drain- age, edema, approximation, granulation tissue, presence and condition ofdrains, and odor; and palpate edges for ten- derness or pain. Cover the wound with sterile gauze byopening a sterile gauze pack and lightly placing the gauze on the wound without touching the dressing material; remove gloves and perform hand hygiene. Set up the sterile field:prepare sterile equipment using sterile tech- nique on an overbed table. If irrigation is prescribed, pour any prescribed irrigation solution into a sterile basin and drawsolu- tion into the irrigating syringe. Gently irrigate the wound with the prescribed solution from the least contaminated area to the most contaminated area. Use an approved irrigation basin to collect solution from the irrigating procedure. Cleanse the wound with sterile gauze from the least contaminated area to the most contaminated area, using single-stroke motions. Discard the gauze from each stroke and use a new one for the next stroke. If drains are present, use cotton tipped applicators to hold drains up and clean around drain sites using circular strokes, starting near the drain and moving outward from the insertion site using cotton tipped applicators or sterile gauze. Drysites in the same manner using sterile gauze. Apply any prescribed wound antiseptic with a cotton-tipped applicator or sterile gauze, using the same technique as when cleansing the wound. Dress the wound with the prescribed dressings using sterile technique and secure in place. Date/time/initial the dressing and discard supplies as indicated per agency procedures, and remove gloves. Assist the client to a comfortable position and ensure safety; assess pain level. Document the procedure, any related assessments, client response, and any additional procedural responses. Adapted from Perry A, Potter P, Ostendorf W: Clinical nursing skills and techniques, ed 8, St. Louis, 2014, Mosby. *Note: Adapt procedure if irrigation is not prescribed or if the client does not have drains or tubes in place. Always follow agencyprocedures for dressing changes and wound irrigations. 223 CHAPTER 18 Perioperative Nursing Care
- 242. XIII. Wound Dehiscence and Evisceration (Fig. 18-5) A. Description 1. Wound dehiscence is separation of the wound edges at the suture line; it usually occurs 6 to 8 days after surgery. 2. Wound evisceration is protrusion of the internal organs through an incision; it usually occurs 6 to 8 days after surgery. 3. Evisceration is most common among obese cli- ents, clients who have had abdominal surgery, or those who have poor wound-healing ability. 4. Wound evisceration is an emergency. B. Assessment: Dehiscence 1. Increased drainage 2. Opened wound edges 3. Appearance of underlying tissues through the wound C. Assessment: Evisceration 1. Discharge of serosanguineous fluid from a previ- ously dry wound 2. The appearance of loops of bowel or other abdominal contents through the wound 3. Client reports feeling a popping sensation after coughing or turning. D. Interventions (see Priority Nursing Actions) XIV. Ambulatory Care or 1-Day Stay Surgical Units A. General criteria for client discharge 1. Is alert and oriented. 2. Has voided. 3. Has no respiratory distress. 4. Is able to ambulate, swallow, and cough. 5. Has minimal pain. 6. Is not vomiting. 7. Has minimal, if any, bleeding from the incision site. 8. Has a responsible adult available to drive the client home. 9. The surgeon has signed a release form. B. Discharge teaching (Box 18-7) 1. Discharge teaching should be performed before the date of the scheduled procedure. 2. Provide written instructions to the client and family regarding the specifics of care. 3. Instruct the client and family about postopera- tive complications that can occur. 4. Provide appropriate resources for home care support. 5. Instruct the client not to drive, make important decisions, or sign any legal documents for 24 hours after receiving general anesthesia. 6. Instruct the client to call the surgeon, ambulatory center, or emergency department if postoperative problems occur. 7. Instruct the client to keep follow-up appoint- ments with the surgeon. F u n d a m e n t a l s PRIORITYNURSING ACTIONS Evisceration in a Wound 1. Call for help; ask that the surgeon be notified and that needed supplies be brought to the client’s room. 2. Stay with the client. 3. While waiting for supplies to arrive, place the client in a low Fowler’s position with the knees bent. 4. Cover the wound with a sterile normal saline dressing and keep the dressing moist. 5. Take vital signs and monitor the client closely for signs of shock. 6. Prepare the client for surgery as necessary. 7. Document the occurrence, actions taken, and the client’s response. Wound evisceration is protrusion of the internal organs through an incision; it usually occurs 6 to 8 days after sur- gery. Evisceration is most common among obese clients, cli- ents who have had abdominal surgery, or those who have poor wound-healing ability. Wound evisceration is an emer- gency. The nurse immediatelycalls for help and asks that the surgeon be notified and that needed supplies (vital sign mea- surement devices, sterile normal saline, and dressings) be brought to the client’s room. The nurse stays with the client and while waiting for supplies to arrive, places the client in a low Fowler’s position with the knees bent to prevent abdom- inal tension on the abdominal suture line. The nurse covers the wound with a sterile normal saline dressing as soon as supplies are available and keeps the dressing moist. Vital signs are monitored closely, and the client is monitored for signs of shock. The client is prepared for surgeryif neces- sary. The nurse also documents the occurrence, actions taken, and client’s response. Reference Perry, Potter, Ostendorf (2014), pp. 925–926. Dehiscence Evisceration FIGURE 18-5 Complications of wound healing. 224 UNIT IV Fundamentals of Care
- 243. CRITICALTHINK ING W hat Should Y ou Do? Answer: Nursing responsibilities with regard to informed consent for a surgical procedure include witnessing the client’s signing of the consent form, but the nurse must be sure that the client has understood the surgeon’s explanation of the surgery. The nurse needs to document the witnessing of the signing of the consent form after the cli- ent acknowledges understanding the procedure. If the client informs the nurse that the explanation was not fully under- stood, the nurse must notifythe surgeon and the surgeon will need to clarifyanything that was not understood bythe client. Reference: Lewis et al. (2014), pp. 325–326. P RACTI CE Q U ES TI O N S 168. The nurse has just reassessed the condition ofa post- operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6 °C (99.6 °F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing 169. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postopera- tive complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. “Use of an incentive spirometer will help pre- vent pneumonia.” 2. “Close monitoring of your oxygen saturation will detect hypoxemia.” 3. “Administration of intravenous fluids will pre- vent or treat fluid imbalance.” 4. “Early ambulation and administration of blood thinners will prevent pulmonary embolism.” 170. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse. 171. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed con- sent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family mem- ber, following agency policy. 172. Apreoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. “If it’s any help, everyone is nervous before surgery.” 2. “I will be happy to explain the entire surgical procedure to you.” 3. “Can you share with me what you’ve been told about your surgery?” 4. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.” F u n d a m e n t a l s BOX 18-7 Postoperative Discharge Teaching Assess the client’s readiness to learn, educational level, and desire to change or modify lifestyle. Assess the need for resources needed for home care. Demonstrate care of the incision and how to change the dressing. Instruct the client to cover the incision with plastic if shower- ing is allowed. Ensure that the client is provided with a 48-hour supply of dressings for home use. Instruct the client on the importance of returning to the sur- geon’s office for follow-up. Instruct the client that sutures usuallyare removed in the sur- geon’s office 7 to 10 days after surgery. Inform the client that staples are removed 7 to 14 days after surgery and that the skin may become slightly reddened when staples are ready to be removed. Sterile adhesive strips (e.g., Steri-Strips® ) may be applied to provide extra support after the sutures are removed. Instruct the client on the use of medications, their purpose, dosages, administration, and side effects or adverse effects. Instruct the client on diet and to drink 6 to 8 glasses ofliquid a day. Instruct the client about activity levels and to resume normal activities gradually. Instruct the client to avoid lifting for 6 weeks if a major surgi- cal procedure was performed. Instruct the client with an abdominal incision not to lift any- thing weighing 10 pounds or more and not to engage in any activities that involve pushing or pulling. The client usuallycan return to workin 6 to 8 weeks depending on the procedure and as prescribed by the surgeon. Instruct the client about the signs and symptoms of compli- cations and when to call the surgeon. 225 CHAPTER 18 Perioperative Nursing Care
- 244. 173. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of informa- tion in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head ofthe bed elevated 45 to 90 degrees. 174. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking ace- tylsalicylic acid. The nurse determines that the cli- ent needs additional teaching if the client makes which statement? 1. “Aspirin can cause bleeding after surgery.” 2. “Aspirin can cause my ability to clot blood to be abnormal.” 3. “I need to continue to take the aspirin until the day of surgery.” 4. “I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery.” 175. The nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin 176. The nurse is monitoring the status ofa postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants 177. Aclient who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protrud- ing through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head. 178. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 µmol/L) 4. Platelets, 210,000 cells/mm3 (210 Â 103 /µL/ 210 Â 109 /L) 179. The nurse receives a telephone call from the post- anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preopera- tive measurements. 180. The nurse is reviewing a surgeon’s prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after mid- night. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen AN S WERS 168. 1 Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care pro- vider. Atemperature higher than 37.7 °C (100 °F) or lower than 36.1 °C (97 °F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client’s preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, expected postoperative assessment findings. To F u n d a m e n t a l s 226 UNIT IV Fundamentals of Care
- 245. answer this question correctly, you must know the normal ranges for temperature, blood pressure, urinary output, and wound drainage. Note that the urinary output is the only observation that is not within the normal range. Review: Postoperative assessment Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Perfusion Reference: Ignatavicius, Workman (2016), p. 262. 169. 1 Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflam- mation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate con- centration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep- breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embo- lus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usu- ally due to clot formation. Early ambulation and administra- tion of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques. Test-Taking Strategy: Note the strategic words, most appropri- ate. Focus on the subject, client instructions related to cough- ing and deep-breathing techniques. Also, focus on the data in the question and note the relationship between the words coughing and deep-breathing in the question and pneumonia in the correct option. Review: Postoperative complications Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Client Education; Gas Exchange Reference: Perry, Potter, Ostendorf (2014), pp. 597-599, 893. 170. 3 Rationale: The nurse would assist the client to void immedi- ately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. Test-Taking Strategy: Focus on the subject, preoperative care measures. Think about the measures that may be helpful and promote comfort. Oral hygiene should be administered since it may make the client feel more comfortable. A client should be nothing by mouth (NPO) for 6 to 8 hours before surgery rather than 24 hours. A slight increase in blood pressure or pulse is insignificant in this situation. Review: Preoperative care Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Palliation Reference: Ignatavicius, Workman (2016), p. 234. 171. 4 Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the cli- ent is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member’s oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to per- form surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appro- priate in this situation. Also, agency policies regarding informed consent should always be followed. Test-Taking Strategy: Note the strategic words, most appropri- ate. Focus on the data in the question. Eliminate options 1 and 3 first. Option 1 will delay necessary surgery and option 3 is inappropriate. Option 2 is not an acceptable and legal role of a charge nurse. Select option 4 since it is the only legally acceptable option: to obtain a telephone permission from a family member if it is witnessed by 2 persons. Review: The procedures for obtaining informed consent Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Ethics; Health Care Law Reference: Lewis et al. (2014), pp. 325-326, 784. 172. 3 Rationale: Explanations should begin with the information that the client knows. By providing the client with individual- ized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preopera- tive experience. Clients who are calm and emotionally pre- pared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client’s anxiety. Explaining the entire surgical procedure may increase the client’s anxiety. Option 4 avoids the client’s anxiety and is focused on postoperative care. Test-Taking Strategy: Note that the client expresses anxiety. Use knowledge of therapeutic communication techniques. Note that the question contains strategic words, most likely, and also note the words stimulate further discussion. Also use the steps of the nursing process. The correct option addresses assessment and is the only therapeutic response. Review: Therapeutic communication techniques Level of Cognitive Ability: Applying F u n d a m e n t a l s 227 CHAPTER 18 Perioperative Nursing Care
- 246. Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Anxiety; Communication References: Lewis et al. (2014), p. 319; Perry, Potter, Ostendorf (2014), p. 31. 173. 4 Rationale: For optimal lung expansion with the incentive spi- rometer, the client should assume the semi-Fowler’s or high Fowler’s position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. Test-Taking Strategy: Focus on the subject, correct use of an incentive spirometer, and visualize the procedure. Note the words rapidly, loose, and 15 seconds in the incorrect options. Options 1, 2, and 3 are incorrect steps regarding incentive spirometer use. Review: Incentive spirometry Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Client Education; Gas Exchange Reference: Perry, Potter, Ostendorf (2014), pp. 597–599, 893. 174. 3 Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has proper- ties that can alter platelet aggregation and should be discontin- ued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements. Test-Taking Strategy: Note the strategic words, needs additional teaching. These words indicate a negative event query and that you need to select the incorrect client statement. Eliminate options 1 and 2 first because they are comparable or alike. From the remaining options, recalling that aspirin has properties that can alter platelet aggregation will direct you to the correct option. Review: Antiplatelet medications in the preoperative period Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Client Education; Clotting Reference: Ignatavicius, Workman (2016), p. 228. 175. 2 Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic tech- nique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immuno- compromise may place the client at risk. Test-Taking Strategy: Focus on the subject, normal findings in the postoperative period. Eliminate options 1, 3, and 4 because they are comparable or alike and are manifestations of infection. Review: Postoperative assessment Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Infection; Tissue Integrity Reference: Ignatavicius, Workman (2016), p. 264. 176. 1 Rationale: Increasing restlessness is a sign that requires contin- uous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, a manifestation of an evolving complication in the immediate postoperative period. Eliminate each of the incor- rect options because they are comparable or alike and are nor- mal expected findings, especially given the time frame noted in the question. Review: Postoperative assessment Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Safety Reference: Ignatavicius, Workman (2016), pp. 260-261, 741. 177. 1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler’s position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken. Test-Taking Strategy: Focus on the subject, that the client is experiencing wound evisceration. Visualizing this occurrence will assist you in determining that the client would not be placed supine and that ice packs would not be placed on the incision. Review: Evisceration Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Tissue Integrity Reference: Ignatavicius, Workman (2016), p. 264. F u n d a m e n t a l s 228 UNIT IV Fundamentals of Care
- 247. 178. 1 Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-Taking Strategy: Focus on the subject, an abnormal lab- oratory result that needs to be reported. Use knowledge of the normal reference intervals to assist in answering correctly. The hemoglobin value is the only abnormal laboratory finding. Review: Normal laboratory reference levels Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Collaboration Reference: Lewis et al. (2014), pp. 325, 626. 179. 1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established. Test-Taking Strategy: Note the strategic word, first. Use the principles of prioritization to answer this question. Use the ABCs—airway, breathing, and circulation. Ensuring airway patency is the first action to be taken, directing you to the cor- rect option. Review: Postoperative care Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Care Coordination; Clinical Judgment Reference: Ignatavicius, Workman (2016), p. 258. 180. 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the abil- ity of the body to withstand stress. When stress is severe, corti- costeroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given paren- terally rather than orally. Ferrous sulfate is an oral iron prepa- ration used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before sur- gery without undue effects on the client. Test-Taking Strategy: Focus on the subject, the medication that should be administered in the preoperative period. Use knowledge about medications that may have special implica- tions for the surgical client. Prednisone is a corticosteroid. Recall that when stress is severe, such as with surgery, cortico- steroids are essential to life. Review: Corticosteroids in the preoperative period Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Clinical Judgment; Collaboration Reference: Lewis et al. (2014), pp. 320–321. F u n d a m e n t a l s 229 CHAPTER 18 Perioperative Nursing Care
- 248. F u n d a m e n t a l s CH AP TER 19 Positioning Clients PRIORITYCONCEPT Mobility; Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse is caring for a client who is receiving intermittent tube feedings via a nasogastric tube. In maintaining proper position- ing for this client, what actions should the nurse take? Answer located on p. 234. For reference throughout the chapter, please see Figures 19-1, Figure 19-2, Figure 19-3, and Figure 19-4. I. Guidelines for Positioning A. Client safety and comfort 1. Position client in a safe and appropriate manner to provide safety and comfort. 2. Select a position that will prevent the develop- ment of complications related to an existing condition, prescribed treatment, or medical or surgical procedure. B. Ergonomic principles related to body mechanics (Box 19-1) Always review the health care provider’s (HCP’s) prescription, especially after treatments or procedures, and take note of instructions regarding positioning and mobility. II. Positions to Ensure Safety and Comfort A. Integumentary system 1. Autograft: After surgery, the site is immobilized usually for 3 to 7 days to provide the time needed for the graft to adhere and attach to the wound bed. 2. Burns of the face and head: Elevate the head of the bed to prevent or reduce facial, head, and tracheal edema. 3. Circumferential burns of the extremities: Elevate the extremities above the level of the heart to pre- vent or reduce dependent edema. 4. Skin graft: Elevate and immobilize the graft site to prevent movement and shearing of the graft and disruption of tissue; avoid weight-bearing. B. Reproductive system 1. Mastectomy a. Position the client with the head of the bed elevated at least 30 degrees (semi-Fowler’s Trendelenburg’s Fowler’s Reverse Trendelenburg’s Flat Semi-Fowler’s FIGURE 19-1 Bed positions. BOX 19-1 Body Mechanics (Ergonomic Principles) for Health Care Workers When planning to move a client, arrange for adequate help. Use mechanical aids if help is unavailable. Encourage the client to assist as much as possible. Keep the back, neckand pelvis, and feet aligned. Avoid twisting. Flex knees, and keep feet wide apart. Raise the client’s bed so that the client’s weight is at the level of the nurse’s center of gravity. Position self close to the client (or object being lifted). Use arms and legs (not back). Slide client toward yourself,using a pullsheet.When transferring a client onto a stretcher, a slide board is more appropriate. Set (tighten) abdominal and gluteal muscles in preparation for the move. Person with the heaviest load coordinates efforts of the team involved by counting to 3. Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. Perry, Potter, Ostendorf (2014), pp. 197-198. St. Louis: Mosby. 230
- 249. position), with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes. b. Turn the client only to the back and unaffected side. 2. Perineal and vaginal procedures: Place the client in the lithotomy position. F u n d a m e n t a l s Lateral (side-lying) position Semiprone (Sims’or forward side-lying) position Supine position Prone position. The client’s arms and shoulders may be positioned in internal or external rotation. FIGURE 19-3 Client positions. FIGURE 19-2 Lithotomy position for examination. FIGURE 19-4 Pressure points in lying and sitting positions. 231 CHAPTER 19 Positioning Clients
- 250. F u n d a m e n t a l s C. Endocrine system 1. Hypophysectomy: Elevate the head of the bed to prevent increased intracranial pressure. 2. Thyroidectomy a. Place the client in the semi-Fowler’s to Fowler’s position to reduce swelling and edema in the neck area. b. Sandbags or pillows or other stabilization devices may be used to support the client’s head or neck. c. Avoid neck extension to decrease tension on the suture line. D. Gastrointestinal system 1. Hemorrhoidectomy: Assist the client to a lateral (side-lying) position to prevent pain and bleeding. 2. Gastroesophageal reflux disease: Reverse Trende- lenburg’s position may be prescribed to promote gastric emptying and prevent esophageal reflux. 3. Liver biopsy (see Priority Nursing Actions) PRIORITYNURSING ACTIONS Liver Biopsy 1. Explain the procedure to the client. 2. Ensure that informed consent has been obtained. 3. Position the client supine, with the right side of the upper abdomen exposed; the client’s right arm is raised and extended behind the head and over the left shoulder. 4. Remain with the client during the procedure. 5. After the procedure, assist the client into a right lateral (side-lying) position and place a small pillow or folded towel under the puncture site. 6. Monitor vital signs closely after the procedure and mon- itor for signs of bleeding. 7. Document appropriate information about the procedure, client’s tolerance, and postprocedure assessment findings. For the client undergoing liver biopsy(or anyinvasive pro- cedure), the procedure is explained to the client and informed consent is obtained bythe health care provider performing the procedure. Since the liver is located on the right side of the upper abdomen, the client is positioned supine, with the right side ofthe upper abdomen exposed. In addition, the right arm is raised and extended behind the head and over the left shoul- der. This position provides for maximal exposure of the right intercostal spaces. The nurse remains with the client during the procedure to provide emotionalsupport and comfort. After the procedure, the client is assisted into a right lateral (side- lying) position and a small pillow or folded towel is placed under the puncture site for at least 3 hours or as prescribed, to provide pressure to the site and prevent bleeding. Vitalsigns are monitored closely after the procedure and the client is monitored for signs of bleeding. The nurse documents appro- priate information about the procedure, the client’s tolerance, and postprocedure assessment findings. Reference Lewis et al. (2014), pp. 882–883. 4. Paracentesis:Client is usuallypositioned in a semi- Fowler’s position in bed, or sitting upright on the side ofthe bed or in a chair with the feet supported; client is assisted to a position of comfort following the procedure. 5. Nasogastric tube a. Insertion (1) Position the client in a high Fowler’s posi- tion with the head tilted forward. (2) This position will help to close the tra- chea and open the esophagus. b. Irrigations and tube feedings (1) Elevate the head of the bed (semi- Fowler’s to Fowler’s position) to prevent aspiration. (2) Maintain head elevation for 30 minutes to 1 hour (per agency procedure) after an intermittent feeding. (3) The head of the bed should remain ele- vated for continuous feedings. If the client receiving a continuous tube feeding needs to be placed in a supine position when providing care, such as when giving a bed bath or changing linens, shut off the feeding to prevent aspiration. Remember to turn the feeding back on and check the rate of flow when the client is placed back into the semi-Fowler’s or Fowler’s position. 6. Rectal enema and irrigations: Place the client in the left Sims’ position to allow the solution to flow by gravity in the natural direction of the colon. 7. Sengstaken-Blakemore and Minnesota tubes a. Not commonly used because they are uncom- fortable for the client and can cause complica- tions, but their use may be necessary when other interventions are not feasible. b. If prescribed, maintain elevation of the head of the bed to enhance lung expansion and reduce portal blood flow, permitting effective esophagogastric balloon tamponade. E. Respiratory system 1. Chronic obstructive pulmonary disease: In advanced disease, place the client in a sitting position, leaning forward, with the client’s arms over several pillows or an overbed table; this position will assist the client to breathe easier. 2. Laryngectomy (radical neck dissection): Place the client in a semi-Fowler’s or Fowler’s position to maintain a patent airway and minimize edema. 3. Bronchoscopy postprocedure: Place the client in a semi-Fowler’s position to prevent choking or aspiration resulting from an impaired ability to swallow. 232 UNIT IV Fundamentals of Care
- 251. F u n d a m e n t a l s 4. Postural drainage: The lung segment to be drained should be in the uppermost position; Trendelenburg’s position may be used. 5. Thoracentesis a. During the procedure, to facilitate removal of fluid from the pleural space, position the client sitting on the edge of the bed and lean- ing over the bedside table with the feet sup- ported on a stool, or lying in bed on the unaffected side with the client in Fowler’s position. b. After the procedure, assist the client to a posi- tion of comfort. Always checkthe HCP’s prescription regarding posi- tioning for the client who had a thoracotomy, lung wedge resection, lobectomy of the lung, or pneumonectomy. F. Cardiovascular system 1. Abdominal aneurysm resection a. After surgery, limit elevation of the head of the bed to 45 degrees to avoid flexion of the graft. b. The client may be turned from side to side. 2. Amputation of the lower extremity a. During the first 24 hours after amputation, elevate the foot of the bed (the residual limb is supported with pillows but not elevated because of the risk of flexion contractures) to reduce edema. b. Consult with the HCP and, if prescribed, position the client in a prone position twice a day for a 20- to 30-minute period to stretch muscles and prevent flexion contractures of the hip. 3. Arterial vascular grafting of an extremity a. To promote graft patency after the procedure, bed rest usually is maintained for approxi- mately 24 hours and the affected extremity is kept straight. b. Limit movement and avoid flexion of the hip and knee. 4. Cardiac catheterization a. Ifthe femoral vessel was accessed for the proce- dure, the client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depend- ingon HCP preference and if a vascular closure device was used); the client may turn from side to side. b. The affected extremity is kept straight and the head is elevated no more than 30 degrees (some HCPs prefer a lower head position or the flat position) until hemostasis is ade- quately achieved. 5. Heart failure and pulmonary edema: Position the client upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion. Most often, clients with respiratory and cardiac dis- orders should be positioned with the head of the bed elevated. 6. Peripheral arterial disease a. Obtain the HCP’s prescription for positioning. b. Because swelling can prevent arterial blood flow, clients may be advised to elevate their feet at rest, but they should not raise their legs above the level of the heart because extreme elevation slows arterial blood flow; some cli- ents may be advised to maintain a slightly dependent position to promote perfusion. 7. Deep vein thrombosis a. If the extremity is red, edematous, and pain- ful, traditional heparin sodium therapy may be initiated. Bed rest with leg elevation may also be prescribed for the client. b. Clients receiving low-molecular-weight hepa- rin usually can be out of bed after 24 hours if pain level permits. 8. Varicose veins: Leg elevation above heart level usually is prescribed; the client also is advised to minimize prolonged sitting or standing during daily activities. 9. Venous insufficiency and leg ulcers: Leg elevation usually is prescribed. G. Sensory system 1. Cataract surgery: Postoperatively, elevate the head of the bed (semi-Fowler’s to Fowler’s posi- tion) and position the client on the back or the nonoperative side to prevent the development of edema at the operative site. 2. Retinal detachment a. If the detachment is large, bed rest and bilat- eral eye patching may be prescribed to mini- mize eye movement and prevent extension of the detachment. b. Restrictions in activity and positioning fol- lowing repair of the detachment depends on the HCP’s preference and the surgical pro- cedure performed. H. Neurological system 1. Autonomic dysreflexia: Elevate the head of the bed to a high Fowler’s position to assist with ade- quate ventilation and assist in the prevention of hypertensive stroke. If autonomic dysreflexia occurs, immediately place the client in a high Fowler’s position. 233 CHAPTER 19 Positioning Clients
- 252. F u n d a m e n t a l s 2. Cerebral aneurysm: Bed rest is maintained with the head of the bed elevated 30 to 45 degrees to prevent pressure on the aneurysm site. 3. Cerebral angiography a. Maintain bed rest for the length of time as prescribed. b. The extremity into which the contrast medium was injected is kept straight and immobilized for about 6 to 8 hours. 4. Stroke (brain attack) a. In clients with hemorrhagic strokes, the head of the bed is usually elevated to 30 degrees to reduce intracranial pressure and to facilitate venous drainage. b. For clients with ischemic strokes, the head of the bed is usually kept flat. c. Maintain the head in a midline, neutral posi- tion to facilitate venous drainage from the head. d. Avoid extreme hip and neck flexion; extreme hip flexion may increase intratho- racic pressure, whereas extreme neck flexion prohibits venous drainage from the brain. 5. Craniotomy a. The client should not be positioned on the site that was operated on, especially if the bone flap has been removed, because the brain has no bony covering on the affected site. b. Elevate the head of the bed 30 to 45 degrees and maintain the head in a midline, neutral position to facilitate venous drainage from the head. c. Avoid extreme hip and neck flexion. 6. Laminectomy and other vertebral surgery a. Logroll the client. b. When the client is out of bed, the client’s back is kept straight (the client is placed in a straight-backed chair) with the feet resting comfortably on the floor. 7. Increased intracranial pressure a. Elevate the head of the bed 30 to 45 degrees and maintain the head in a midline, neutral position to facilitate venous drainage from the head. b. Avoid extreme hip and neck flexion. Do not place a client with a head injury in a flat or Trendelenburg’s position because of the risk of increased intracranial pressure. 8. Lumbar puncture a. During the procedure, assist the client to the lateral (side-lying) position, with the back bowed at the edge of the examining table, the knees flexed up to the abdomen, and the neck flexed so that the chin is resting on the chest. b. After the procedure, place the client in the supine position for 4 to 12 hours, as prescribed. 9. Spinal cord injury a. Immobilize the client on a spinal back- board, with the head in a neutral position, to prevent incomplete injury from becoming complete. b. Prevent head flexion, rotation, or extension; the head is immobilized with a firm, padded cervical collar. c. Logroll the client; no part of the body should be twisted or turned, nor should the client be allowed to assume a sitting position. I. Musculoskeletal system 1. Total hip replacement a. Positioning depends on the surgical techniques used (anterior or posterior approach), the method of implantation, the prosthesis, and sur- geon’s preference. b. Avoid extreme internal and external rotation. c. Avoid adduction; in most cases side-lying is per- mitted as long as an abduction pillow is in place; some surgeons allow turning to only 1 side. d. Maintain abduction when the client is in a supine position or positioned on the nonopera- tive side. e. Place a wedge (abduction) pillow between the client’s legs to maintain abduction; instruct the client not to cross the legs f. Check the HCP’s prescriptions regarding eleva- tion of the head of the bed and hip flexion. 2. Devices used to promote proper positioning (Box 19-2) CRITICALTHINK ING W hat Should Y ou Do? Answer: For the client receiving intermittent tube feedings via a nasogastric tube, the nurse should position the client in an upright (semi-Fowler’s or high Fowler’s) position during the feeding and for 30 minutes to 1 hour following the feeding, per agency procedure. Positioning the client in an upright position prevents aspiration of the formula. For the client receiving a continuous tube feeding, an upright position should be maintained at all times. Reference: Perry, Potter, Ostendorf (2014), p. 778. 234 UNIT IV Fundamentals of Care
- 253. P RACTI CE Q U ES TI O N S 181. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims’ position with the head of the bed flat 4. Prone with the head turned to the side and sup- ported by a pillow 182. Thenurseiscaringfora clientfollowinga craniotomy, in which a largetumorwasremoved from theleft side. In which position can thenursesafelyplacetheclient? Refer to the figures in options 1 to 4. 1. 2. 3. 4. 183. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a depen- dent position 184. The nurse is caring for a client who is 1 day postop- erative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated F u n d a m e n t a l s BOX 19-2 Devices Used for Proper Positioning Bed Boards These plywood boards are placed under the entire surface area of the mattress and are useful for increasing back support and body alignment. Foot Boots Foot boots are made of rigid plastic or heavyfoam and keep the foot flexed at the proper angle. They should be removed 2 or 3 times a day to assess skin integrity and joint mobility. Hand Rolls Hand rolls maintain the fingers in a slightly flexed and func- tional position and keep the thumb slightly adducted in oppo- sition to the fingers. Hand-Wrist Splints These splints are individually molded for the client to maintain proper alignment of the thumb in slight adduction and the wrist in slight dorsiflexion. Pillows Pillows provide support, elevate body parts, splint incisional areas, and reduce postoperative pain during activity, coughing, or deep breathing. Theyshould be ofthe appropriate size for the body part to be positioned. Sandbags Sandbags are soft devices filled with a substance that can be shaped to body contours to provide support. They immobilize extremities and maintain specific body alignment. Side Rails These bars, positioned along the sides of the length of the bed, ensure client safety and are useful for increasing mobility. They also provide assistance in rolling from side to side or sitting up in bed. Laws regarding the use of side rails vary state to state and these laws must be followed; therefore, agency policies must be followed. Trapeze Bar This bar descends from a securely fastened overhead bar attached to the bed frame. It allows the client to use the upper extremities to raise the trunk offthe bed, assists in transfer from the bed to a wheelchair, and helps the client to perform upper arm–strengthening exercises. Trochanter Rolls These rolls prevent external rotation of the legs when the client is in the supine position. To form a roll, use a cotton bath blan- ket or a sheet folded lengthwise to a width extending from the greater trochanter of the femur to the lower border of the pop- liteal space. Wedge Pillow This triangular pillow is made of heavy foam and is used to maintain the legs in abduction following total hip replacement surgery. Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. 235 CHAPTER 19 Positioning Clients
- 254. 185. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instruc- tions? 1. “I should sleep on my left side.” 2. “I should sleep on my right side.” 3. “I should sleep with my head flat.” 4. “I should not wear my glasses at any time.” 186. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims’ position 2. Right Sims’ position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees 187. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg’s 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows 188. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a posto- perative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremitycovered with a blanket. 189. The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider’s (HCP’s) prescription and plans to allow which cli- ent position or activity following the procedure? 1. Bed rest in high Fowler’s position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees 190. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler’s 3. High Fowler’s 4. Supine with the head flat AN S WERS 181. 2 Rationale: To facilitate removal of fluid from the chest, the cli- ent is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims’ positions are inappropriate positions for this procedure. Test-Taking Strategy: Focus on the subject, positioning for thoracentesis. To perform a thoracentesis safely, the site must be visible to the health care provider (HCP) performing the pro- cedure. The client should be placed in a position where he or she is as comfortable as possible with access to the affected side. A prone position would not give the HCP access to the chest. Lying on the affected side would prevent access to the site. Review: Positioning for thoracentesis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Diagnostic Tests Priority Concepts: Clinical Judgment; Safety References: Lewis et al. (2014), pp. 493, 550; Perry, Potter, Ostendorf (2014), p. 1110. 182. 1 Rationale: Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be posi- tioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position or Trendelenburg’s position would increase intracranial pressure. Areverse Trendelenburg’s position would not be helpful and may be uncomfortable for the client. Test-Taking Strategy: Focus on the subject, positioning fol- lowing craniotomy. Remember that a primary concern is the risk for increased intracranial pressure. Therefore, use concepts related to gravity and preventing edema and increased intracra- nial pressure to answer this question. Review: Positioning following craniotomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Intracranial Regulation; Safety Reference: Ignatavicius, Workman (2016), p. 960. F u n d a m e n t a l s 236 UNIT IV Fundamentals of Care
- 255. 183. 3 Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Aflat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. Test-Taking Strategy: Focus on the subject, the safe position or activity for the client with deep vein thrombosis. Think about the pathophysiology associated with this disorder and the principles related to gravity flow and edema to answer the question. Review: Positioning for a venous disorder Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Safety Priority Concepts: Perfusion; Safety Reference: Ignatavicius, Workman (2016), p. 731. 184. 2 Rationale: Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider’s (HCP’s) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided to prevent displacement of the prosthesis. Test-Taking Strategy: Focus on the strategic word, best. Use knowledge regarding care of clients following total hip replace- ment to answer this question. After a total hip replacement, the client should never have the extremity internally or externally rotated. Lying on the surgical side can cause damage to the sur- gical replacement site. Review: Positioning after total hip replacement Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Implementation Content Area: Fundamentals of Care—Safety Priority Concepts: Mobility; Safety Reference: Lewis et al. (2014), p. 1526. 185. 1 Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema for- mation and intraocular pressure. The client also should be placed in a semi-Fowler’s position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient. Test-Taking Strategy: Focus on the subject, right cataract sur- gery. Use of the principles of gravity and edema formation will assist in answering this question. Remember to instruct the cli- ent to remain off the operative side and to rest with the head elevated to minimize edema formation. This will assist you when answering questions related to cataract surgery. Review: Positioning following cataract surgery Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Fundamentals of Care—Safety Priority Concepts: Client Teaching; Sensory Perception Reference: Lewis et al. (2014), pp. 393-394. 186. 1 Rationale: For administering an enema, the client is placed in a left Sims’position so that the enema solution can flow by grav- ity in the natural direction of the colon. The head of the bed is not elevated in the Sims’ position. Test-Taking Strategy: Focus on the subject, positioning for enema administration. Use knowledge regarding the anatomy of the bowel to answer the question. The descending colon is located on the lower left side of the body. The head of the bed should be flat during enema administration. Review: Enema administration Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Skills Priority Concepts: Elimination; Safety Reference: Perry, Potter, Ostendorf (2014), pp. 853-854. 187. 4 Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescrip- tions regarding positioning following amputation. Test-Taking Strategy: Focus on the subject, positioning fol- lowing amputation, and note that the client has just returned from surgery. Using basic principles related to immediate post- operative care and preventing edema will assist in directing you to the correct option. Review: Positioning following amputation Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Perfusion; Tissue Integrity Reference: Lewis et al. (2014), p. 1532. 188. 2 Rationale: Autografts placed over joints or on lower extremi- ties are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon’s preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extrem- ity with a blanket can disrupt the graft site. Test-Taking Strategy: Focus on the subject, positioning fol- lowing autograft. Use general postoperative principles; elevat- ing the graft site will decrease edema to the graft. The client should not be placed in a prone position or have it covered after surgery since it can disrupt a graft easily. Review: Positioning following autograft Level of Cognitive Ability: Creating F u n d a m e n t a l s 237 CHAPTER 19 Positioning Clients
- 256. Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Perioperative Care Priority Concepts: Perfusion; Tissue Integrity References: Ignatavicius, Workman (2016), p. 484. Lewis et al. (2014), pp. 466–467. 189. 4 Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP’s preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved. Test-Taking Strategy: Focus on the subject, positioning fol- lowing cardiac catheterization. Think about this diagnostic procedure and what it entails. Understanding that the head of the bed is never elevated more than 30 degrees and bath- room privileges are restricted in the immediate postcatheteriza- tion period will assist in answering this question. Review: Positioning following cardiac catheterization Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Fundamentals of Care—Diagnostic Tests Priority Concepts: Perfusion; Safety Reference: Ignatavicius, Workman (2016), p. 644. 190. 3 Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler’s position to facilitate inser- tion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler’s and supine positions place the client at risk for aspiration; in addi- tion, these positions do not facilitate insertion of the tube. Test-Taking Strategy: Focus on the subject, insertion of a nasogastric tube. Visualize each position and think about how it may facilitate insertion of the tube. Also, recall that a concern with insertion of a nasogastric tube is pulmonary aspi- ration. Placing the client in a high Fowler’s position with his or her chin to the chest will decrease the risk of aspiration. Review: Positioning for nasogastric tube insertion Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Fundamentals of Care—Skills Priority Concepts: Clinical Judgment; Safety Reference: Perry, Potter, Ostendorf (2014), p. 778. F u n d a m e n t a l s 238 UNIT IV Fundamentals of Care
- 257. F u n d a m e n t a l s CH AP TER 20 Care of a Client with a Tube PRIORITYCONCEPTS Caregiving, Safety CRITICALTHINK ING W hat Should Y ou Do? The nurse assesses a client with a closed chest tube drainage system. On inspection, the nurse notes that the system is cracked. What should the nurse do? Answer located on p. 251. I. Nasogastric Tubes A. Description 1. These are tubes used to intubate the stomach. 2. The tube is inserted from the nose to the stomach. B. Purpose 1. To decompress the stomach by removing fluids or gas to promote abdominal comfort 2. To allow surgical anastomoses to heal without distention 3. To decrease the risk of aspiration 4. To administer medications to clients who are unable to swallow 5. To provide nutrition by acting as a temporary feeding tube 6. To irrigate the stomach and remove toxic sub- stances, such as in poisoning C. Types of tubes 1. Levin tube (Fig. 20-1) a. Single-lumen nasogastric tube b. Used to remove gastric contents via intermit- tent suction or to provide tube feedings 2. Salem sump tube: A Salem sump is a double- lumen nasogastric tube with an air vent (pigtail) used for decompression with intermittent con- tinuous suction (see Fig. 20-1). The air vent on a Salem sump tube is not to be clamped and is to be kept above the levelofthe stomach. If leakage occurs through the air vent, instill 30 mLof air into the air vent and irrigate the main lumen with normal saline (NS). D. Intubation procedures (Box 20-1) E. Irrigation 1. Assess placement before irrigating (see Box 20-1). 2. Perform irrigation every 4 hours to assess and maintain the patency of the tube. 3. Gently instill 30 to 50 mL of water or NS (depending on agency policy) with an irrigation syringe. 4. Pull back on the syringe plunger to withdraw the fluid to check patency; repeat if the tube flow is sluggish. F. Removal of a nasogastric tube: Ask the client to take a deep breath and hold it; remove the tube slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it). II. Gastrointestinal Tube Feedings A. Types of tubes and anatomical placement 1. Nasogastric: Nose to stomach 2. Nasoduodenal-nasojejunal: Nose to duodenum or jejunum 3. Gastrostomy: Stomach 4. Jejunostomy: Jejunum B. Types of administration 1. Bolus a. A bolus resembles normal meal feeding patterns. b. Formula is administrated over a 30- to 60- minute period every 3 to 6 hours; the amount of formula and frequency can be recom- mended by the dietitian and is prescribed by the health care provider (HCP). 2. Continuous a. Feeding is administered continually for 24 hours. b. An infusion feeding pump regulates the flow. 3. Cyclical a. Feeding is administered in the daytime or nighttime for approximately 8 to 16 hours. b. An infusion feeding pump regulates the flow. c. Feedings at night allow for more freedom during the day. 239
- 258. C. Administration of feedings 1. Check the HCP’s prescription and agency policy regarding residual amounts; usually, if the residual is less than 100 mL, feeding is administered; large- volume aspirates indicate delayed gastricemptying and place the client at risk for aspiration. 2. Assess bowel sounds; hold the feeding and notify the HCP if bowel sounds are absent. 3. Position the client in a high Fowler’s position; if comatose, place in high Fowler’s and on the right side. 4. Assesstubeplacement byaspiratinggastriccontents and measuring the pH (should be 3.5 or lower). 5. Aspirate all stomach contents (residual), mea- sure the amount, and return the contents to the stomach to prevent electrolyte imbalances (unless the color or characteristics of the residual is abnormal or the amount is greater than 250 mL). 6. Warm the feeding to room temperature to pre- vent diarrhea and cramps. 7. Use an infusion feeding pump for continuous or cyclic feedings. 8. For bolus feeding, maintain the client in a high Fowler’s position for 30 minutes after the feed- ing. Use an infusion pump or allow the feeding to infuse via gravity. Do not plunge the feeding into the stomach. 9. For a continuous feeding, keep the client in a semi-Fowler’s position at all times. F u n d a m e n t a l s Lavacuator tube An orogastric tube with a large suction lumen and a smaller lavage/vent lumen that provides continuous suction because irrigating solution enters the lavage lumen while stomach contents are removed through the suction lumen. Used to remove toxic substances from the stomach. An ewald tube is similar but has a single lumen. Cantor tube A single-lumen long tube with a small inflatable bag at the distal end. A special substance (tungsten) is injected with a needle (gauge 21 or smaller or balloon may leak) and syringe into the bag of the tube. Sengs taken-Blakemore tube A three-lumen tube. Two ports inflate an esophageal and a gastric balloon for tamponade, and the third is used for nasogastric suction. This tube does not provide esophageal suction, but a nasogastric tube may be inserted in the opposite naris or the mouth and allowed to rest on top of the esophageal balloon. Esophageal suction is then possible, reducing the risk of aspiration. Weighted flexible feeding tube with s tylet Access port with irrigation adaptor allows maintenance of the tube without disconnecting the feeding set. Levin tube A plastic or rubber single-lumen tube with a solid tip that may be inserted into the stomach via the nose or mouth. Used to drain fluid and gas from the stomach. Salem s ump tube A double-lumen tube. The small vent tube within the large suction tube prevents mucosal suction damage by maintaining the pressure in open eyes at the distal end of the tube at less than 25 mm Hg. Miller-Abbott tube A long double-lumen tube used to drain and decompress the small intestine. One lumen leads to a balloon that is filled with a special substance (tungsten) once it is in the stomach; the second is for irrigation and drainage. Open eyes Large suction lumen Lavage/vent lumen Open eyes along tube Solid tip Open eyes Small vent tube Large suction tube Open eye for drainage Balloon filled with a special substance Two lumens Length markings Gastric balloon inflation lumen Gastric aspiration lumen Esophageal balloon Esophageal balloon inflation lumen Gastric balloon Access port Stylet Exit port Weighted tip FIGURE 20-1 Comparison of design and function of selected gastrointestinal tubes. 240 UNIT IV Fundamentals of Care
- 259. D. Precautions Always assess the placement of a gastrointestinal tube before instilling feeding solutions, medications, or any other solution. If the tube is incorrectly placed, the client is at risk for aspiration. 1. Change the feeding container and tubing every 24 hours or per agency policy. 2. Do not hang more solution than is required for a 4-hour period; this prevents bacterial growth. 3. Check the expiration date on the formula before administering. 4. Shake the formula well before pouring it into the container (feeding bag). Some feedings require the use of a bag in which formula is added, or require the use of bottles that feeding tubing can be attached to directly. The tubing some- times has a Y-site connection so a regular flush can be programmed using the pump rather than using a piston syringe. 5. Always assess bowel sounds; do not administer any feedings if bowel sounds are absent. 6. Administer the feeding at the prescribed rate or via gravity flow (intermittent bolus feedings) with a 50- to 60-mL syringe with the plunger removed. 7. Gently flush with 30 to 50 mL of water or NS (depending on agency policy) using the irriga- tion syringe after the feeding. E. Prevention of complications 1. Diarrhea a. Assess the client for lactose intolerance. b. Use fiber-containing feedings. c. Adminis