47. A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?

1. Age 46 years
2. Diet high in fiber
3. BMI of 24
4. History of Crohn's disease

48. A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?

1. "Place your storage container in a recycle bin when it is full."
2. "Remove the needle from the syringe before you place it in the trash."
3. "Secure the cap tightly over the needle before you discard it."
4. "You can discard needles in an empty bleach bottle with a lid."

49. A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia?
50. Abdominal cramping
51. Increased perspiration
52. Dehydration
53. Fruit odor to breath
54. A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following

actions should the nurse take?

1. Familiarize themselves with commonly used signed language.
2. Ask a family member to be present during the admission.
3. Obtain a board that uses colored pictures as communication.
4. Request an interpreter during the initial assessment.

51. A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
    1. Auscultate breath sounds.
    2. Examine the surgical incision for drainage.
    3. Measure the client's core body temperature.
    4. Palpate pulses distal to the graft donor site.

47. A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

1. Would you like to meet with another client who is an amputee?"
2. "Why do you think your life is over?"
3. "You are upset. We can talk about this later."
4. "Most people can adjust following this surgery."

48. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?

1. Indistinct, rambling speech
2. Piloerection of the skin
3. Decreased body temperature
4. Vomiting upon arousal

49. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

1. Collect information about the irritant that caused the injury.
2. Administer proparacaine eyedrops into the affected eye.
3. Instill 0.9% sodium chloride solution into the affected eye.
4. Place a strip of pH paper onto the cul-de-sac of the affected eye.

50. A nurse is providing Instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

1. "You will need cryotherapy for 1 to 2 weeks."
2. You will need to take an antiviral medication for 6 months."
3. You will need three follow-up blood tests within a 24-month period."
4. "You will need to be monitored for 15 minutes after receiving each medication dose."

What is cultural broking? Who are cultural brokers, and how do they impact patient/ provider services? How are you practicing cultural broking? In what ways can you improve your service to patients?

47. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?

1. Remind the client to use a cane on his left side while ambulating.
2. Position the bedside table on the client's left side.
3. Provide the client with a short-handled reacher.
4. Place a plate guard on the client's meal tray.

48. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?

1. Administer IV fluids to the client.
2. Prepare the client for an intravenous pyelogram.
3. Initiate beta blocker therapy.
4. Insert a urinary catheter.

49. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

1. Discard the radioactive device in the client's trash can.
2. Instruct visitors to remain 3 feet from the client.
3. Limit time for visitors to 2 hr per day.
4. Keep so led bed linens in the client's room.

50. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

1. "I should take my daily aspirin on an empty stomach."
2. "I should withhold my metoprolol if my heart rate is above 100 beats per minute."
3. "I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses."
4. "I should lie down before taking a dose of isosorbide dinitrate."

What are the strengths, limitations, and conclusions to the John Hopkins evidence-based practice nursing model?

47. A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?

1. Slow the transfusion rate if the client reports itching.
2. Prime the IV tubing with 0.45% sodium chloride.
3. Complete the transfusion within 2 hr.
4. Administer through a 22-gauge IV catheter.

48. A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?

1. Slow the transfusion rate if the client reports itching.
2. Prime the IV tubing with 0.45% sodium chloride.
3. Complete the transfusion within 2 hr.
4. Administer through a 22-gauge IV catheter.

49. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

1. Apply compression stockings to the lower extremities.
2. Discourage leg exercises while in bed.
3. Place pillows under the client's knees.
4. Avoid use of anticoagulants.

50. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate?

1. "Sucking on a lozenge may reduce the frequency of your cough
2. "increasing your daily fluid intake may eliminate your cough."
3. "Your cough may require that you stop or change your medication."
4. "Your cough should go away in time."

1. A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?

1. "You should wear an N95 respirator mask when you are at home."
2. "Your provider will discontinue your medications after 3 months of therapy."
3. You will need to return in 2 weeks to provide a sputum specimen."
4. "You can drink alcohol after the first 6 weeks of treatment."

2. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs?

1. Weight gain
2. Hair loss
3. Jaundice
4. Polyuria

3. A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client's oral nutritional Intake?

1. Avoid the use of supplemental feedings throughout the day.
2. Adhere to scheduled meal times three times daily.
3. Encourage the client to eat as many calories as possible.
4. Limit the client's fluid intake to 1,500 ml/day.

4. A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

1. "I would rather be in a wheelchair than use a walker to get around."
2. "I've been having problems with bladder control."
3. 11 have difficulty swallowing food."
4. "I have a hard time with brushing my hair."

1. A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

1. Inform the client they might experience a low-grade fever.
2. Provide the client with sips of water.
3. Check the client's gag reflex.
4. Instruct the client to report bleeding.

2. A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

1. "I can't seem to get reading materials far enough away to see the words."
2. "I've noticed that there is a gray ring around the colored part of my eye."
3. "In the last day, I have had a severe headache and pain around my right eye."
4. "I'm having more difficulty telling the difference between blues and greens."

3. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

1. Take tub baths instead of showers.
2. May place a small pillow under the head when sleeping.
3. May operate a motor vehicle when no longer taking analgesics.
4. Increase intake of fiber-rich foods.

4. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

1. "I can keep my medication for 1 year before replacing it."
2. "I should discontinue this medication if I develop a headache."
3. "i can take up to five tablets in 15 minutes before seeking medical attention."
4. "I should lie down when I take this medication."

GU Unit – Chapter 55

Student Readiness Activity

You receive a 56 year old male patient newly admitted to your general medical floor who presented to the ED with complaints of severe right flank pain (rated 10/10 on numeric pain scale), nausea & vomiting for the past 36 hours, fever of 101.5 degrees, hematuria, & dysuria. This patient was diagnosed with a 0.7cm nephrolithiasis in the right kidney, seen on renal ultrasound.

1. Write out 3 nursing diagnoses (include ‘related to’ and ‘as evidenced by’ (AEB) statements) that are appropriate for this patient. Remember you do not need to include AEB statements for ‘risk for’ nursing diagnoses.
2. Identify a patient outcome for each of your nursing diagnoses.
3. Identify 2 nursing interventions for each nursing diagnoses (minimum 6 nursing interventions total) that you would include in your care plan to help the patient achieve their outcomes.

What is endocrine axis and write a sample for one hormone?

Pain Assessments and Interventions:

Assessment: The patient was alert and orientated X 3/ X 2 and reported left hand pain at the IV site as a 5 on a scale from 0-10 at 0900 d/t potassium infusion; heat pack was placed at the site and IV rate was lowered, reassessment at 0930 was a 0. The patient demonstrated facial grimacing during movement and appeared to be discomfort through out clinical shift. She stated pain level as 0 at 0730 and 1430 when vitals were recorded.

Interventions:

Respiratory Assessment and Intervention:

Assessment:Patient on room air. Frequent, nonproductive, dry cough noted after an increase in activity. Patient appears to be in no distress. Barrel chest. Normal lung sounds auscultated in all lung fields. HOB is elevated to 30 degrees. No use of axillary muscles. No signs of pallor or air hunger.

Interventions:

Neurosensory Assessments and Interventions:

Assessment: Patient is alert and orientated X3, sometimes X2. Easily arousal. PEERLA present. No use of corrective lenses/glasses. Patient has slowed, comprehendible speech. Verbal and able to follow two-step commands. Purposeful responses and purposeful movements. Generalized muscle weakness and fatigue.

Interventions:

Cardiovascular Assessments and Interventions:

Assessment: Patient’s HR 75 at 0730 and 79 at 1130. BP 108/60 at 0730 and 107/52. Patient is placed on remote telemetry. S1 and S2 sounds present. All four extremities are warm and dry. Skin turgor immediate recoil. No signs of clubbing/splitting. Dorsalis Pedi +1 weak pulses. Radial pulses +1 weak. Capillary refill less then 3 seconds. Patient’s color is WNL. No peripheral edema. Abdominal ascites present. SCD’s present. Patient has a hx of HTN, coagulopathy and anemia.

Interventions:

Musculoskeletal Assessments and Interventions: (include activity)

Assessment: Patient has limited ROM in all four extremities and needs partial assistance with ADL’s. Decreased ROM in all four extremities: RUE-mild LUE- mild, RLE- moderate, LLE- moderate. Decreased tone in all four extremities. No muscle contractures present. No peripheral edema or tenderness present. No traction or casts present. No abdominal binder. Able to transfer to bedside commode with one assist. Patient is on high fall risk and a bed alarm is set.

Interventions:

Gastrointestinal Assessment and Intervention: (include ordered diet)

Assessment: Patient is on a general diet. Patient did not eat her breakfast; she ate 25% of lunch and 25% of her dinner. Patient’s abdomen was distended and ascites was present. Hypoactive bowel sounds present in all 4 quadrants. Patient given protonix for gastric mobility at 0900. Patient had loose brown/yellow bowel movements 4 X in the commode. Patient was on lactulose, which was discontinued in the AM.

Interventions:

Endocrine Assessment and Intervention:

Assessment: Patient has a hx of DM II. Accuchecks every 6 hours and on a sliding scale. Patient’s glucose was 170 at 1200 and was given Insulin aspart 3 units at 1200. Patient has a history hypothyroidism; synthroid 50 mcg was given on an empty stomach at 0900. Patient does not exhibit diaphoresis, nervousness, or change in skin color. No signs of heat or cold intolerances.

Interventions:

Reproductive Assessment and Intervention:

Assessment: Patient had two children 36 and 40 years ago.

Interventions:

Vascular Access Assessment and intervention:

Assessment: Patient has an IV in her left hand and another IV in her right brachial. Dressing dry and intact. No continuous IV fluids running at this time. No signs of infiltration, redness or phlebitis at either IV site. Patient stated burning at left hand IV site during potassium chloride infusion, infusion lowered and heat pack given.

Interventions:

Safety Assessment and Intervention:

Assessment: Patient is at a high risk for falls. Three-side rails are up and the bed is in the lowest position. Bed alarm is on. Call light is with in reach. Turn patient every two hours to prevent skin break down. Ensure HOB is 30-45 degrees.

Interventions:

Psychosocial Assessment and Interventions:

Assessment: The patient lives in a house in Chicago with her son Tommy. She has two grandchildren that came to visit her at the bedside. She was a former smoker and alcoholic. She stated that she currently drinks one mixed drink of vodka each day. Her husband passed away 15 years ago and that’s when her drinking got bad. She stated, “I’m not as bad of a drinker as my father was.” She stated that she enjoys cooking because it makes her feel happy, however has not been able to cook as much because of her limited mobility and pain.

Interventions:

When using a mechanical lift to transfer a patient out of bed the nurse is aware of which of the following to ensure safety except?

A patient who is 4 days post–coronary artery bypass surgery reports she is having new chest pain that is “different from my angina pain.” The pain’s onset was 5 or 6 hours ago upon first waking up in the morning. The patient has a new pericardial friction rub and a low-grade fever of 100.5°F. The patient is diagnosed with acute pericarditis. a. Why was this patient at risk for developing pericarditis? b. Why is this patient now at risk for cardiac tamponade? c. What are the signs or symptoms that would be indicative of cardiac tamponade in this patient? What is the underlying pathophysiology of these signs and symptoms?

Write a critical appraisal of an evidence-based translation model in nursing including the name of the model, who developed it, why it was developed, the steps of the model, strengths, and weaknesses of the model and how the model can be used to support evidence-based practice.