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The nurse is preparing to care for a client postureterolithotomy who has a ureteral catheter in place. The nurse should plan to implement which action in the management of this catheter when the client arrives from the recovery room?
- A. Clamp the catheter.
- B. Place tension on the catheter.
- C. Check the drainage from the catheter.
- D. Irrigate the catheter using 10 mL sterile normal saline.
Correct Answer: C
Rationale: Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific primary health care provider's prescription to do so.
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A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?
- A. Trim the rough edges of the cast after it is dry.
- B. Weight bearing on the right leg is allowed once the cast feels dry.
- C. Expect burning and tingling sensations under the cast for 3 to 4 days.
- D. Keep the right ankle elevated above the heart level with pillows for 24 hours.
Correct Answer: D
Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
An emergency department nurse prepares to plan care for a child diagnosed with acetaminophen overdose. The nurse reviews the primary health care provider's prescriptions and prepares to administer which medication?
- A. Succimer
- B. Vitamin K
- C. Acetylcysteine
- D. Protamine sulfate
Correct Answer: C
Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally or via nasogastric tube in a diluted form with water, juice, or soda. It can also be administered intravenously (undiluted). Protamine sulfate is the antidote for heparin. Succimer is used in the treatment of lead poisoning. Vitamin K is the antidote for warfarin.
While preparing to administer an intravenous (IV) medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention should the nurse implement to assure the client's safety?
- A. Ask the provider to prescribe a compatible IV solution.
- B. Start a new IV catheter for the incompatible medication.
- C. Collaborate with the provider for a new administration route.
- D. Flush tubing before and after administering the medication with normal saline.
Correct Answer: D
Rationale: When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route is unnecessary because a simpler, less risky, viable option exists.
The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.