BSN Hesi 266 Medical surg

The correct answer is C. Strict IV fluid replacement.

Explanation:

The client who had gastric bypass surgery 2 weeks ago is showing signs that could indicate an anastomosis leak, which is a serious and potentially life-threatening complication. Key symptoms of this complication include:

Abdominal tenderness (which could indicate peritonitis or infection)

Fever (temperature 101°F), which indicates infection or inflammation.

Tachycardia (heart rate 130 beats/minute), tachypnea (respiratory rate 26 breaths/minute), and hypotension (BP 100/50 mmHg), which are signs of systemic infection or hypovolemic shock (which can occur due to fluid loss from a leak into the abdomen or peritoneal cavity).

These symptoms indicate that the client is likely experiencing a serious complication, such as an infection or sepsis, which can lead to hypovolemic shock. Strict IV fluid replacement is crucial to maintain the client’s circulatory volume and to support blood pressure, which is low. Fluids will also help counteract the electrolyte imbalances that may occur with this condition.

Why the other options are incorrect:

a. Encourage regular turning:

While turning the client regularly is important to prevent pressure ulcers, the priority in this case is to manage the fluid status and treat the potential anastomosis leak, which may require emergency intervention. Turning will not address the immediate life-threatening issues like hypovolemia or infection from a leak.

b. Monitor skin for breakdown:

Skin breakdown is important to monitor, especially in a postoperative client who may have limited mobility. However, this is a secondary concern compared to addressing the risk of shock and the potential for infection or fluid loss due to the anastomosis leak.

d. Assess wound drainage daily:

While assessing wound drainage is crucial to detect any signs of infection or leakage, it is not as critical as stabilizing the client’s fluid status and managing the hemodynamic instability first. The priority intervention should focus on fluid resuscitation and managing shock, as the client is showing signs of hypotension, which requires immediate intervention.

Summary:

In the case of possible anastomosis leakage after gastric bypass surgery, the most important intervention is to ensure strict IV fluid replacement to manage potential hypovolemic shock and support the client’s vital signs. Other interventions, such as monitoring skin and wound drainage, are also important but are secondary to addressing the fluid and hemodynamic issues associated with the possible leakage and systemic infection.

Correct Answer: D. Advise the client to remain in bed with the leg elevated.

Explanation

The aching pain, redness, and warmth in the lower calf are classic signs of deep vein thrombosis (DVT), a serious postoperative complication. The priority intervention is to keep the client on bed rest with the affected leg elevated to prevent the clot from dislodging and causing a pulmonary embolism (PE). Elevating the leg promotes venous return, reduces swelling, and helps prevent further clot formation.

Why the Other Options Are Incorrect:

A. Apply sequential compression devices (SCDs) bilaterally.

SCDs are used to prevent DVT, but should not be applied once a DVT is suspected or diagnosed. Using SCDs on the affected leg can dislodge the clot, increasing the risk of a pulmonary embolism (PE), which can be life-threatening.

B. Assess for a positive Homan's sign in each leg.

Homan’s sign (pain in the calf upon dorsiflexion of the foot) is not a reliable diagnostic tool for DVT and is no longer recommended in clinical practice. Performing this test can also dislodge the clot and increase the risk of embolism. Instead, the nurse should notify the healthcare provider for further assessment and possible diagnostic tests like a Doppler ultrasound.

C. Pad all bony prominences on the affected leg.

 Padding bony prominences is useful for preventing pressure ulcers but does nothing to treat a suspected DVT. The priority intervention in this case is to keep the client on bed rest and elevate the leg while awaiting further medical evaluation.

Summary:

A client with postoperative aching, redness, and warmth in the calf likely has a DVT. The most appropriate intervention is to keep the client on bed rest with the leg elevated to prevent complications like pulmonary embolism. SCDs should not be applied, Homan’s sign is unreliable and potentially dangerous, and padding bony prominences does not address the DVT.

The correct answer is: d. Begin straining all urine

Explanation

Hyperparathyroidism often results in elevated calcium levels in the blood, which can lead to the formation of kidney stones (calcium-based stones). The flank pain that the client reports is a typical symptom of a kidney stone. Straining all urine allows the nurse to catch any stones that may pass, which is important for both diagnostic purposes and ensuring that no stones are left behind that could cause further damage or obstruction to the urinary system.

Why the other options are incorrect:

a. Implement seizure precautions. While elevated calcium levels (hypercalcemia) can lead to neuromuscular disturbances, including seizures, seizure precautions are not the immediate priority when a client presents with flank pain likely related to a kidney stone. The priority is addressing the potential kidney stone causing the pain.

b. Initiate cardiac telemetry. Hypercalcemia can affect cardiac function, but the priority in this case is to assess and manage the potential for a kidney stone. Telemetry may be necessary if the client exhibits symptoms such as arrhythmias or significant changes in vital signs, but it is not the first intervention in the context of flank pain.

c. Administer a PRN dose of a laxative. There is no indication that this client has constipation or bowel-related issues that would necessitate the use of a laxative. The client's flank pain is more likely to be related to kidney stones, which require a different approach.

Summary

In the case of a client with hyperparathyroidism and sudden onset flank pain, the nurse's priority intervention is to begin straining all urine to monitor for kidney stones that could be causing the pain. This helps with diagnosis and management of potential kidney stones.

Correct Answer: A. Teach the client techniques of intermittent self-catheterization.

Explanation

Multiple sclerosis (MS) is a neurological disorder that affects nerve conduction, leading to sensorimotor deficits, including bladder dysfunction. Urinary retention in MS occurs due to impaired detrusor muscle contraction or failure of sphincter relaxation, resulting in incomplete emptying of the bladder. Intermittent self-catheterization (ISC) is the gold standard for managing neurogenic bladder dysfunction in MS. ISC prevents bladder overdistention, reduces the risk of urinary tract infections (UTIs), and helps maintain independence and quality of life. Teaching the client proper sterile technique and frequency of catheterization is essential in preventing complications.

Why the Other Options Are Incorrect:

B. Decrease fluid intake to prevent overdistention of the bladder.

While it might seem logical to limit fluids to prevent urinary retention, reducing fluid intake can lead to dehydration, increased risk of urinary tract infections, and more concentrated urine, which can irritate the bladder. Proper hydration is necessary to support bladder function and overall health.

C. Use incontinence briefs to maintain hygiene with urinary dribbling.

Urinary dribbling often occurs due to overflow incontinence, a consequence of urinary retention rather than actual bladder control loss. Using incontinence briefs does not address the root cause of urinary retention and can lead to skin irritation and infections. Instead, the goal should be to promote bladder emptying through self-catheterization.

D. Explain that anticholinergic drugs will decrease muscle spasticity.

Anticholinergic medications are typically used to reduce bladder spasms and manage overactive bladder, but they can worsen urinary retention by further inhibiting bladder contractions. This is not an appropriate intervention for a client experiencing urinary retention due to a sensorimotor deficit.

Summary:

For a client with urinary retention due to multiple sclerosis, the most effective nursing intervention is teaching intermittent self-catheterization, as it promotes bladder emptying, prevents complications, and enhances quality of life. Decreasing fluids, using incontinence briefs, or administering anticholinergic drugs do not effectively address urinary retention and may worsen the condition.

Correct Answer: D. Adequate cellular nourishment.

Explanation

Polyphagia, or excessive hunger, is a classic symptom of diabetes mellitus, especially when blood glucose levels are poorly controlled. It occurs because glucose cannot enter the cells due to insulin deficiency or resistance, leading to cellular starvation. The body compensates by increasing hunger in an attempt to obtain more energy. The priority outcome for a client experiencing polyphagia is ensuring adequate cellular nourishment, which is achieved by improving glucose metabolism through insulin or other glucose-lowering therapies.

Why the Other Options Are Incorrect:

A. Fluid and electrolyte balance.

Although diabetes can lead to fluid and electrolyte imbalances, especially in cases of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), polyphagia itself is not directly related to dehydration or electrolyte disturbances. Instead, excessive thirst (polydipsia) and frequent urination (polyuria) are more relevant to fluid balance concerns in diabetes.

B. Prevention of water toxicity.

Water toxicity, or hyponatremia due to excessive water intake, is not typically a concern in diabetes-related polyphagia. While excessive thirst (polydipsia) may lead to excessive water intake, the kidneys usually excrete excess fluid to prevent water toxicity. This option is more relevant in conditions like syndrome of inappropriate antidiuretic hormone secretion (SIADH).

C. Reduced glucose in the urine.

Although glycosuria (glucose in the urine) is a sign of poor glucose control, it is not the primary outcome for managing polyphagia. The main goal is to improve glucose uptake by the cells so they receive adequate nourishment. Reducing urine glucose is an effect of proper diabetes management but not the primary priority when addressing polyphagia.

Summary:

Polyphagia occurs in diabetes because cells are deprived of glucose due to insufficient insulin or insulin resistance. The priority outcome is ensuring that cells receive adequate nourishment, which is best achieved through proper blood glucose control. While fluid balance, glycosuria, and water toxicity may be concerns in diabetes, they are not directly related to polyphagia. Thus, ensuring adequate cellular nourishment is the most appropriate goal.

The correct answer is: b. Move the client to a private room, keep the door closed, and initiate droplet precautions.

Explanation:

The client is exhibiting symptoms of COVID-19, including fever, cough, and shortness of breath, and has had potential exposure to the virus eight days ago. Given that COVID-19 is primarily spread through respiratory droplets, the most important action is to prevent the transmission of the virus to others.

Move the client to a private room, keep the door closed, and initiate droplet precautions:

COVID-19 is transmitted via respiratory droplets, and droplet precautions are necessary to prevent the spread of the virus to healthcare workers and other patients. This includes placing the patient in a private room, keeping the door closed, wearing a mask (surgical or N95, depending on the facility guidelines), gloves, and a gown when interacting with the patient. Initiating these precautions is crucial to minimizing the risk of transmission until the test results are available.

Why the other options are incorrect:

a. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient:

While it is important to inform family members about the risk of exposure to COVID-19, the immediate priority for the nurse is ensuring that the symptomatic patient is properly isolated and precautions are in place to prevent the spread of the virus. Monitoring family members can be done later, but it is not as urgent as addressing the patient’s isolation and infection control measures.

c. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:

Currently, antiviral medications such as remdesivir are used in specific situations for hospitalized patients with severe COVID-19 or those at high risk for complications. However, antiviral treatment should not be initiated until a confirmed positive test result is obtained, and the decision to administer antivirals would depend on the patient’s condition and healthcare provider’s orders. Starting an IV infusion without a confirmed diagnosis and the appropriate orders is not appropriate at this time.

d. Assist the client to recall everyone possibly exposed since onset symptoms:

While it is important to notify individuals who may have been exposed to the virus, the primary focus right now should be on isolating the symptomatic patient to prevent the spread of the virus. The nurse should ensure the client is isolated and precautions are taken before addressing exposure notification, which is generally done by public health authorities or healthcare providers.

Summary

The most important action is to move the client to a private room, keep the door closed, and initiate droplet precautions to prevent the transmission of COVID-19 to others. Proper isolation and infection control are critical in managing the patient's symptoms and preventing further spread of the virus, while other actions, such as counseling family members and starting antiviral treatment, are secondary to immediate patient safety and containment.

The correct answer is d. Wearing gloves when handling cold items guards against painful spasms.

Explanation:

Raynaud's disease is a condition where blood vessels in the fingers and toes constrict excessively in response to cold or stress, leading to pain, discoloration, and sometimes numbness. The primary concern in managing Raynaud's disease is avoiding triggers that lead to vasoconstriction and the painful episodes associated with it.  Wearing gloves when handling cold items is an important preventive measure because it helps protect the hands from cold exposure, which can trigger the vasospasm and painful episodes characteristic of Raynaud’s disease. By keeping the hands warm, the client can help prevent the constriction of blood vessels and reduce pain associated with Raynaud's attacks.

Why the other options are incorrect:

a. Painful areas should be rubbed gently until the pain subsides.

Rubbing the painful areas is not recommended as it can further damage or irritate the affected area, especially in cases of severe vasospasm. The focus should be on avoiding cold exposure, managing stress, and using warming techniques rather than physical manipulation.

b. Return appointments will be needed for IV pain medications.

While Raynaud’s disease can be painful, it is typically managed with preventive measures (such as avoiding cold exposure, using warming strategies, and possibly medications like calcium channel blockers to improve blood flow) rather than requiring IV pain medications. Chronic pain due to Raynaud's does not usually require IV medication, especially as a routine treatment.

c. Enrolling in a pain clinic can provide relief alternatives.

A pain clinic may be useful in some chronic pain conditions, but for Raynaud's disease, the treatment primarily focuses on avoiding triggers (like cold exposure) and possibly medications that promote blood flow. Enrolling in a pain clinic is not typically the first-line recommendation for this condition.

Summary:

For a client with Raynaud’s disease, wearing gloves when handling cold items is the most effective preventive strategy to manage painful spasms by keeping the hands warm and reducing the chance of vasoconstriction. Other options, such as rubbing the affected area or relying on pain clinics for treatment, are not appropriate or necessary in managing this disease.

The correct answer is B: Drink 3 liters of water each day.

Explanation:

After a transurethral resection of the prostate (TURP), it is crucial to keep the urinary system functioning properly to help prevent clot formation, ensure that the catheter remains patent, and reduce the risk of infection. The most important instruction for the client is to drink plenty of fluids—about 3 liters per day—unless contraindicated by another medical condition. Drinking 3 liters of water per day helps to flush out the urinary tract, prevents dehydration, and ensures that the urine remains diluted. This can help reduce the risk of clot formation, especially important for clients recovering from TURP, where bleeding is a potential concern. Proper hydration also helps to avoid urinary tract infections (UTIs) and keeps the urinary catheter functioning effectively by ensuring a good flow of urine.

Why the other options are wrong:

A: Avoid driving a car for 2 weeks: While it is important to avoid certain activities like driving if the client is experiencing pain, discomfort, or is still on medications that can impair reaction times (e.g., pain relievers), avoiding driving is not the most critical instruction related to urinary health or postoperative recovery after TURP. The primary concern is maintaining proper urinary function and preventing complications like infection or bleeding.

C: Eliminate all spicy foods from your diet: There is no direct connection between spicy foods and recovery after TURP unless the client experiences specific gastrointestinal issues like heartburn or irritation. In general, dietary restrictions should focus on hydration and maintaining a balanced, nutritious diet to aid in recovery. Spicy foods are not inherently harmful unless the client has a sensitivity to them, but this is not a primary concern after TURP surgery.

D: Clamp the catheter when taking a shower: Clamping the catheter is generally not advised because it can lead to urinary retention or increase the risk of infection. In most cases, the catheter should be left unclamped to allow continuous drainage of urine. The client should be instructed on proper catheter care and cleaning techniques to reduce the risk of infection while showering, but clamping the catheter is typically not recommended unless instructed by the healthcare provider.

Summary:

The most important instruction for the nurse to include in the discharge teaching plan for a client recovering from TURP with an indwelling urinary catheter is to drink 3 liters of water each day. This will help ensure proper urinary flow, prevent clot formation, and reduce the risk of infection. The other options are less critical for immediate recovery and should be addressed in context, depending on the client’s individual situation.

The correct answer is: A. Start an IV nitroglycerin infusion.

Explanation:

Vasopressin (Pitressin) is a vasoconstrictor used to treat esophageal variceal bleeds, as it constricts blood vessels to reduce bleeding. However, a common side effect of vasopressin is ischemic chest pain or angina due to the vasoconstrictive effects on coronary vessels. The substernal tightness and pressure that the client is reporting may be indicative of chest pain related to myocardial ischemia caused by vasopressin. In this case, the nurse should initiate IV nitroglycerin (a vasodilator) to relieve the chest pain and dilate the coronary arteries, improving blood flow to the heart muscle.

Why the other options are incorrect:

B. Nasogastric lavage with cool saline: This procedure would be appropriate in cases of upper GI bleeding (such as with varices) to remove blood or substances in the stomach, but it does not address the client’s substernal chest pain. The pain is likely related to the vasopressin infusion, and treating it with a vasodilator is more appropriate.

C. Increase the vasopressin infusion: Increasing the vasopressin infusion would be counterproductive as it would worsen the vasoconstriction and could exacerbate the chest pain. The patient is already experiencing chest discomfort likely due to the vasoconstricting effects of vasopressin, so increasing the dose would be inappropriate.

D. Prepare for endotracheal intubation: There is no indication from the provided information that the client is having respiratory distress or airway compromise that would require intubation. The issue seems to be related to chest pain, which should be addressed with a vasodilator rather than a procedure like intubation

Summary:

When a client receiving vasopressin for esophageal variceal rupture reports substernal chest tightness and pressure, the nurse should initiate IV nitroglycerin (a vasodilator) to relieve potential myocardial ischemia or angina caused by vasopressin’s vasoconstrictive effects.