Nokea
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
- A. Pain level
- B. Vital signs
- C. Hourly urine output
- D. Tolerance for sips of clear liquids
- E. Ability to cough and deep breathe
Correct Answer: A,B,C,E
Rationale: After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.
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A client diagnosed with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field when the client makes which statement?
- A. I'll be able to wash the ink marks off my skin after the initial treatment.
- B. Direct sunlight is something I'll have to really avoid exposing my skin to.
- C. I'll have my family bring me some unscented lotion to keep my skin soft.
- D. Wearing snug fitting clothing over the skin site will help provide good support.
Correct Answer: B
Rationale: The client undergoing radiation therapy must keep the affected skin protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). The client should wash the site using mild soap and warm or cool water and pat the area dry. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. No lotions, creams, alcohol, perfumes, or deodorants should be placed on the skin over the treatment site. The client should wear cotton clothing over the skin site and guard against irritation from tight or rough clothing such as belts or bras.
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety?
- A. Use the right arm blood pressure measurement.
- B. Use the fistula for all venipunctures and intravenous infusions.
- C. Ensure that small clamps are attached to the AV fistula dressing.
- D. Assess the fistula for the presence of a bruit and thrill every 4 hours.
Correct Answer: D
Rationale: AV fistulas are created by anastomosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the risk of clotting, infection, or damage to the fistula. The fistula is not used for venipunctures or intravenous infusions for the same reason. Clamps may be needed for an external device such as an AV shunt, but the AV fistula is internal.
A client with a central venous catheter who is receiving total parenteral nutrition (TPN) suddenly experiences signs/symptoms associated with an air embolism. The nurse should implement which interventions to minimize the client's risk for injury? Select all that apply.
- A. Monitors vital signs
- B. Clamps the catheter
- C. Checks the line for air
- D. Notifies the primary health care provider
- E. Boluses the client with 500 mL normal saline
- F. Places the client in Trendelenburg position on the left side
Correct Answer: B,D,F
Rationale: If the client experiences air embolus, the client is placed in the lateral Trendelenburg position on the left side to trap the air in the right atrium. The nurse should also clamp the catheter and notify the primary health care provider. Although vital signs are monitored continuously, doing without a related action does not directly assist the client. A fluid bolus would cause the air embolus to travel.
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.