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Caring for a client receiving Radiation Therapy

Use an electric shaver


Avoid using heat
Wash the affected area w/ pain water
*cover the affected area w/ loose clothing to protect the skin from sun exposure

Instructing a client to self-administer epoetin-alfa


The nurse should instruct the client to self-administer eoptin-alfa via subcutaneous route
Avoid shaking the vial
Never freeze the medication
Insert the needle @ 45 degree angle
Note: the Z-track method is used for the IM injections only!

Do-not-resuscitate (DNR) prescriptions


The nurse should ensure there is a DNR prescription order on the client’s medical record
before any surgical procedure to follow legal guidelines

Reinforcing teachings with an older adult client who ha osteoarthritis


The nurse should recommend low-impact aerobic exercises
Apply warm, moist heat to manage the joint pain caused by osteoarthritis
*The nurse should instruct the client to apply capsaicin cream topically to provide
warmth and relieve joint pain. The client should apply the cream no more than times
daily to avoid skin irritations.

Reinforcing teaching w/ a client about the use of elastic stockings to decrease Peripheral
Edema
The nurse should instruct the client to apply elastic stockings in the morning and remove
@ the end of the day before bed time.
Elevate legs 15-30 minutes prior to applying the elastic stockings to decrease swelling
and improve circulation

Caring for a client receiving continuous bladder irrigation following a TURP


Transurethral resection of the prostate
The nurse should maintain the flow rate of the bladder irrigation to keep the urine
diluted to a reddish-pink color & the tubing free of clots and bleeding
Use sterile technique to clear the catheter tubing
Use sterile 0.9% sodium chloride solution for bladder irrigation

Caring for a client who has a gastrostomy tube


The nurse should flush the feeding tube with 30-60 mL of water of the tube becomes
clogged to re-establish the patency of the tube
Instill 30 mL of water every 4 hours

Caring for a client w/ Dependent Personality Disorder


Clients who have DPD have problems making everyday decisions independently
Caring for a client w/ Paranoid Personality Disorders
The client is concerned about what others will think

Caring for a client w/ Histrionic Personality Disorder


The client continues to relate real stories about past intimate relationships

Therapeutic responses to a client in mental health facility


The nurse should always validate the client s concern

Caring for a client who has Rubeola


The nurse should initiate air-borne precautions for a client who has rubeola
This includes a private room w/ negative air pressure
Faculty are required to wear a N95 mask while in the patients room

Caring for client on Droplet Precautions


The nurse should initiate droplet precautions of bacteria & viruses that can be
transmitted
The nurse should wear a mask when within 3 feet of the client

Caring for a client on Contact Precautions


The nurse should don gown and gloves before caring for the client

Reinforcing discharge planning with a client who has a prescription for a home
oxygen therapy via nasal cannula
The nurse should instruct the client to notify the provider if shortness of breath
Apply water-based lubricant to prevent irritation
Secure oxygen tanks in an upright position

Assisting a client who is post-operative to sit on the side of the bed


The nurse should assist the client to a side-lying position toward the edge of the bed
where he plans to sit
*Elevate the head of the bed
The nurse should stand w/feet wide apart with the foot closest to the bed in front of
the other foot
The nurse should position one arm over the clients thigh and the other arm under the
clients shoulder to prevent the client from falling backwards

Caring for FOUR clients who need care


When establishing priority care, always use ABC’s (airway, breathing, circulation)

Caring for a client receiving Morphine through a PCA Pump


*the client should increase fluid intake to prevent the adverse effects of constipation
Only the client should activate the PCA dosing
The nurse should reinforce the need to administer a dose prior to procedures or activities
To eliminate discomfort
Caring for a client w/ Pneumonia
The nurse should include the client’s preferences on the plan of care
The nurse should include the client’s anticipated plan for discharge to determine of the
client will have special home care needs such as oxygen

Caring for a client who has Asthma and is taking Montelukast


Montelukast, a leukotriene modifier, is taken once a day at bed time
This medication is taken on a regular basis for the treatment of asthma

Caring for a client who has second thoughts about having Surgery
The nurse should encourage the client to express concerns or feelings

Caring for a client who has An NG Tube w/ continuous enteral feeding


The nurse should measure the pH prior to administering nutrition
A result of 5 or less indicates the tube resides in the stomach
Withhold the feeding if more than 100 mL is obtained
Change the enteral feeding bag and tubing every 24 hours
Aspirate the gastric residual every 4 hours

Expected findings when collecting urine specimen for a client w/ Diabetes Insipidus
The nurse should expect to see a creatinine level of 100 mL/min and
Clients who have colorless urine w/ a specific gravity of 1.005 or less

Reinforcing teaching w/ a client taking Metronidazole


Instruct the client to expect dark reddish-brown urine and a dry mouth

Indicative of a positive client response to Systematic Desensitization


The purpose of desensitization therapy is to teach the client to use relaxation techniques
to overcome the anxiety caused by the phobia. The nurse should recognize the clients
lack of anxiety when thinking about the phobia as positive response to the therapy

Identifying client needs for a referral to inter-professional team members


Speech pathologist: For a client who is not eating due to difficulty swallowing
Dietician: for a client who requires a diet to meet nutritional needs
Occupational Therapist: for a client who needs help using special eating utensils
Physical therapist: for a client who has difficulty w/ mobility
Determining Which Client(s) to Recommend for Discharge in a Disaster Situation
.Unstable clients: Unstable clients are the most severe and, as such, are not candidates for
discharge or transfer to another nursing care unit or relocation.
Stable clients: Stable clients who continue to need nursing and medical care and assistance are
the second priority and, therefore, should not discharged until the lowest priority clients are
discharged or transferred and there is a continued need for more reallocation of resources
because higher acuity and higher priority clients need necessary care and services during the
disaster.
Ambulatory clients and self-care clients: Ambulatory clients and self-care clients who need little
or no assistance are the first clients to be safely discharged, transferred or relocated.

Administering Nystatin oral suspension to a client who has oral candidiasis


The nurse should advise the client to hold the medication in the mouth for 2 minutes prior
to swallowing or spitting out the medication.
The client should wait 30 minutes before eating drinking or brushing teeth

Assisting w/ the plan of care for a client who has bipolar disorder and is in the manic
phase.
During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse
should include physical activity such as walking in the plan of care. Additionally, the
one-on one nature of the activity provides the client with a sense of security

Assisting w/ the care of a client who has terminal cancer


Reminiscence is a normal task of the grieving process that allows the family to cope as
the client a life nears its end.

Reinforcing teaching about strategies to promote eating w/ a client who has COPD
The nurse should instruct the client to drink high protein and high calorie nutritional
supplements to maintain respiratory muscle function. COPD causes respiratory stress that
leads to wasting of the clients muscle mass
Avoid salt
Limit fluid intake while eating

Preparations to perform blood glucose monitoring for a client w/ Type 1 Diabetes


Mellitus
Evidence based practice indicates that the nurse should FIRST position the testing site to
enhance blood flow, which improves the ability to collect an adequate specimen

Assisting a client w/ Almzheimer’s disease who is agitated


A client w/ Alzheimer disease experiences chronic confusion. Guiding to a quiet, familiar
place will help decrease agitation
Finding information on client’s Electronic Medical record
Graphic record- weight, vital signs
Consultation report- client interventions
Admission sheet- DOB, occupation, health insurance
Nurses notes: Response to treatments

Caring for an older adult client w/ difficulty sleeping


Avoid caffeine including green tea
Have a night light in the room for safety
Provide the client a light snack such as whole grain crackers

Time Management strategies to use


Document medication as soon as administered
Prepare a client priority task to-do-list

Techniques to transfer a client form the bed to a chair


Use lower body strength when lifting a client to reduce stress on the back
Avoid twisting the lower back
Place the bed in the lowest position and ensure the wheels are locked
Stand with feet and shoulders apart w/one foot slightly forward

Laboratory results for a client 2 days post-operative following thoracic surgery that s/b be
reported to HCP
WBC
Hgb
Blood glucose
BUN

Characteristics of a vulnerable person at risk for intimate partner violence


The nurse should include pregnancy as a characteristic placing a vulnerable person at
risk. The perpetrator might selfishly view the pregnancy as a threat to the relationship

Standard precaution guidelines to clean up a blood spill


Chlorine bleach will kill all bloodborne pathogens

Infection control precautions for a client who has Hepatitis A and is incontinent
Hepatitis A is spread by fecal-oral route and should use contact precautions

Informed Consent
The nurse should ask the client if he/she understands the procedure before witnessing the
signature on the informed consent
The nurse should notify the surgeon if the client lacks understanding the procedure
The client has the right to refuse the procedure at any time with or w/o consent
Identifying manifestations of preclampsia
Increase blood pressure (monitor BP daily in same arm so reading is consistent
Weight gain (weigh self at the same time each day)
Consume 8 ox glass of water each day (to maintain renal function)
Avoid grapefruit juice because this will increase the effect of nifedipine and cause severe
Hypotension

Diagnostic Tests
Antinuclear antibody test- used to detect autoimmune disorders
Sputum culture- used to detect the presence of a respiratory disease such as pneumonia
Lumbar test is performed to obtain cerebrospinal fluid to confirm bacterial meningitis
Partial thromboplastin- used to monitor a client receiving heparin or bleeding disorders

Caring for a client who is in the active stage of dying


Administer atropine to reduce the clients respiratory secretions
Position the client on the right side to minimize nausea
Speak to the client using a warm calm voice
The client who is dying has a deceased blood circulation and would not absorb
medication administed by injection. Use oral, IV,subcuataneous transdermal, instead

Steps to removing client in case of fire


RACE

Caring for a newborn who is 12 hours old stools


The first stool passed by a new born is the meconium that develops in utero. It is dark
green and viscous
Formula fed newborns have light brown stools
Breast fed newborns have golden yellow stools

Caring for a new mother who is receiving Fentanyl


Fentanyl, an opioid agonist, rapidly crosses the placenta, the nurse should monitor the
newborn for respiratory depression, which is an adverse effect to this medication

Exercise to promote Hyperextension of the shoulder


Moving arm behind body while keeping the elbows straight

Reinforcing teaching w/ a client scheduled for a Lumbar Puncture


Client should increase fluid intake
Client should remain flat for a minimum of 1 hour following the procedure

Identifying adventitious breathing sounds


Wheezing: Wheezes are continuous musical tones that are most commonly heard at end
inspiration or early expiration
Fine Crackles: short high pitched crackle sounds heard during end of inspiration
Stridor: High pitched crowing sound that can often be heard w/o a stethoscope
Friction Rub: a dry rubbing or grating sound
Adverse Effects of anabolic steroid use
Use of anabolic steroids can lead to premature growth such as height and breast
Enlargements

Reinforcing teachings of self-administration of Enoxaparin


Enoxaparin (lovenox) is an anticoagulant (blood thinner) used to treat/prevent blood clots
Used only by subcutaneous injection underneath the skin
Must be given at different sites

Steps in caring for a minor burn


Gently clean w/ mild soap and water
Remove any debris
Apply ointment
Wrap in dressing
Initial and date
Document

Car Restraint Safety


Children should ride in booster seat until 4’9” or 8 years old
All children should remain in the rear facing until 2 years old
The vehicle lap belt must lie low across the upper thighs, not the stomach. The shoulder
belt should rest snugly across the shoulder and chest, not across the neck or face.

Reinforcing teaching w/client who has hypertension and is taking captopril


Captopril is an ace inhibitor used to treat hypertension
*do not use OTC drugs such as ibuprofen, ibuprofen decreases effects of captopril
by opposing drug effects.

Caring for a client who experiences a Tonic-Clonic Seizure


Avoid putting anything in the client’s mouth
The nurse should keep the client in a side lying position to prevent aspiration

Caring for a client w/ Chronic Hepatitis symptoms


The client w/ chronic hepatitis will experience tenderness in the upper right quad, which
is where the nurse should palpate. This is where the liver is located.

Adverse effects of a client prescribed Morphine


Morphine is a narcotic pain killer
Adverse effect include constipation, hypotension and respiratory depression causing low
respiratory rate < 10

Reinforcing teachings to a client taking atorvastatin (Lipitor)


Used to treat high cholesterol
The nurse should instruct the client to report muscle pain or tenderness
Reinforcing teachings to a client taking Hydralzine
A vasodilator used to treat hypertension
The nurse should monitor for orthostatic hypotension

Reinforcing teachings to a client taking antihistamines


Used to treat allergies
The nurse should monitor for urinary retention

Reinforcing teachings to a client taking Anticoagulants


Used to treat/prevent blood clots
The nurse should monitor for any signs of bleeding

Monitoring a an older adult client w/ a hip fracture


the nurse should monitor for muscles spasms which can lead to external rotation and
shortening of the affected leg

Identifying a potential safety hazard


If possible, remove any potential equipment hazards or non-working equipment from the
client’s room

Identifying indications of hyperglycemia


Hyperglycemia is high blood sugar
S/S include tachycardia (increased heart rate), polyuria (excessive urination), and flushed
dry skin

Identifying indications of hypoglycemia


Hypoglycemia is low blood sugar
S/S include fatigue, dizziness, shakiness, pale skin, heart palpitations

Preparing to administer IM Immunizations to a preschooler


When preparing a preschooler for a procedure, the nurse should use “play” to assist the
child in understanding the procedure

Reinforcing teachings to a client who is to follow a 2000 mg sodium restricted diet


Canned peaches have a low sodium content

Maintaining Client confidentiality


Do not share client information with anyone that does not have a direct impact in the care
or w/o client’s permission

Example of Defense Mechanism: Rationalization


The means of justifying unreasonable feelings, thoughts or actions
Ex: “I failed because my teacher hates me”
Example of Defense Mechanism: Denial
Avoiding or blocking out thoughts, pain or feelings
Ex: a patient waiting 3 days to seek help from a doctor

Example of Defense Mechanism: Compensation


Makes excuses
Ex: a student nurse who feels she can’t pass the nclex, becomes a nursing assistant

Examples of Defense Mechanism: Suppression


Putting things off
A client has an appointment to get teeth pulled, and purposely didn’t go

Reinforcing teachings w/ a client who has alcohol use disorder and is taking disulfiram
therapy
the nurse should advise the client that a thorough exam is needed, an informed consent
The medication should be taken once a sayb