Nursing Education Capstone (C947)

Correct Answer:

B) Level of consciousness

Explanation:

The Glasgow Coma Scale (GCS) is specifically designed to assess a patient's level of consciousness by evaluating three key aspects: eye opening, verbal response, and motor response. It helps to determine the severity of brain injury and monitor changes in the patient's neurological status. The GCS is a widely used tool in assessing a patient's level of consciousness, which can provide crucial information about the patient's neurological function.

Why other options are wrong:

A) Reflex activity: The GCS does not assess reflex activity. Reflexes may be assessed separately through other neurological exams, such as checking deep tendon reflexes.

C) Cognitive ability: While GCS scores may give some indirect information about cognitive function, it is primarily a measure of consciousness rather than cognitive abilities, such as memory or problem-solving.

D) Sensory involvement: Sensory involvement, such as touch, temperature, or pain perception, is not specifically assessed through the GCS. Sensory tests are usually done through a separate neurological assessment.

Correct Answer

a. Vital signs

Explanation

Before beginning a blood transfusion, it is critical for the nurse to assess the client's vital signs. This establishes a baseline for comparison during and after the transfusion to detect any potential transfusion reactions. Monitoring vital signs, especially temperature, pulse, blood pressure, and respiratory rate, helps to identify early signs of complications such as fever, allergic reactions, or circulatory overload. The baseline also helps guide clinical decisions if any issues arise during the transfusion.

Why other options are wrong

b. Skin color

While skin color may provide some clues about circulation or oxygenation, it is not the priority for assessment immediately before starting a blood transfusion. Vital signs provide more immediate, actionable data that will be crucial for monitoring the patient’s condition during the transfusion.

c. Urine output

Urine output is an important indicator of kidney function and fluid balance but does not provide immediate information on how the patient is responding to the transfusion. The priority before starting the transfusion is to assess the baseline vital signs for detecting potential immediate reactions.

d. Latest hematocrit level

The latest hematocrit level is useful in assessing the client’s overall blood volume and oxygen-carrying capacity but does not provide the immediate, real-time data needed to monitor for acute reactions during the transfusion. Vital signs are more crucial in detecting complications as the transfusion proceeds.

Correct Answer:

D) A BP of 105/68 mmHg

Explanation:

A blood pressure of 105/68 mmHg is within the normal range and does not indicate an issue. In managing polycystic kidney disease, maintaining a healthy blood pressure is crucial, but this reading is not a cause for concern. The other options (burning on urination, fever, and shortness of breath) could indicate complications such as urinary tract infection or fluid retention, which should be promptly addressed.

Why other options are wrong:

A) Burning on urination: Burning on urination could indicate a urinary tract infection (UTI), which is a common complication in PKD. UTIs should be evaluated and treated promptly to avoid further kidney damage or infection.

B) Temp of 100.6F: A temperature of 100.6°F may indicate a fever, which is a common sign of infection, such as a UTI or kidney infection. This should be reported to the healthcare provider for further evaluation.

C) New onset of shortness of breath: Shortness of breath can indicate fluid retention, which is a complication that can arise in PKD due to kidney dysfunction. This requires immediate medical evaluation to assess for heart failure or other serious issues.

Correct Answer

C. "This test is done to ensure adequate collateral circulation"

Explanation

The Allen's test is performed to assess whether the ulnar artery can adequately supply blood to the hand if the radial artery is used for arterial blood gas sampling. This ensures that collateral circulation exists, which is critical to prevent ischemia in case the radial artery is compromised during the procedure. A proper understanding of this purpose is reflected in the client’s statement regarding collateral circulation.

Why other options are wrong

A. "Blood is drawn from the ulnar artery"

This is incorrect because arterial blood gases are typically drawn from the radial artery, not the ulnar artery. The Allen’s test evaluates the ulnar artery’s function as a backup, not the primary site for blood draw. Misunderstanding the site of the blood draw indicates a lack of comprehension.

B. "I know I have to lie down while blood is drawn"

While positioning is important in some procedures, arterial blood gas sampling does not require the patient to lie down. This statement does not relate to the purpose of the Allen’s test, which is to check blood flow rather than patient position.

D. "Direct pressure has to be placed over the site for 15 minutes after blood is drawn"

Although pressure is applied to the site to prevent bleeding or hematoma, especially in patients on anticoagulants, this is standard care for any arterial puncture and not specific to the Allen’s test. Therefore, this response does not demonstrate an understanding of the test's actual purpose.

Correct Answer

b. Tell the UAP to stop trying to insert anything into the mouth

Explanation

During a seizure, it is dangerous to insert anything into the client’s mouth, including an oral airway, as this can cause injury to the teeth, mouth, or airway. The nurse should instruct the UAP to stop attempting to insert the airway and should focus on ensuring the client’s safety by protecting the head and body from injury. The primary nurse is responsible for assessing and providing the appropriate care during the seizure.

Why other options are wrong

a. Help the UAP insert the oral airway in the mouth

Inserting an oral airway during a seizure is not recommended, as the client is unable to protect their airway or manage the insertion process. This can lead to injury or obstruction of the airway, so the nurse should not assist in this action.

c. Take no action, the UAP handling the situation

The nurse has a responsibility to oversee patient care and ensure that appropriate interventions are being implemented. Leaving the UAP to handle the situation without intervention is unsafe, as the nurse is responsible for guiding the care, especially in emergencies such as seizures.

d. Notify the charge nurse of the situation immediately

While it may be necessary to notify the charge nurse eventually, the immediate concern is ensuring the client’s safety during the seizure. Stopping the UAP from attempting to insert the airway and managing the situation directly is the nurse’s primary responsibility.

Correct Answer

b. Hyperkalemia

Explanation

Hyperkalemia is a potentially life-threatening condition that can occur in patients on hemodialysis, especially when they miss dialysis appointments. Hemodialysis is responsible for removing excess potassium from the bloodstream, and when dialysis is missed, potassium levels can build up to dangerous levels. Elevated potassium can lead to cardiac arrhythmias, which can be fatal if not addressed promptly. Monitoring and managing potassium levels is critical in dialysis patients to prevent complications.

Why other options are wrong

a. Hypoglycemia

Hypoglycemia is not a primary concern in patients on hemodialysis, particularly if they have missed dialysis appointments. While insulin and certain medications can contribute to hypoglycemia, it is not the immediate risk in this context. Hyperkalemia is a more common and immediate concern.

c. Hyponatremia

Hyponatremia, or low sodium levels, is a concern in some medical conditions but is not typically the most pressing issue in patients who have missed dialysis. In fact, dialysis patients are more likely to experience hyperkalemia or fluid imbalances rather than hyponatremia.

d. Hypercalcemia

While hypercalcemia can occur in some renal patients, it is not the most immediate concern following missed dialysis. Hyperkalemia poses a greater immediate risk to the patient’s health, especially in relation to the cardiovascular system.

Correct Answer

D. Progesterone​

Explanation

Progesterone is the key hormone required to maintain pregnancy. It helps prepare the uterus for implantation and supports the early stages of pregnancy by preventing contractions of the uterus, thus maintaining the pregnancy. It is primarily produced by the corpus luteum in the early stages of pregnancy and later by the placenta.

Why other options are wrong

A. Estrogen​

Estrogen is involved in the development of the pregnancy, but it is not as crucial for maintaining it as progesterone. While it supports uterine growth and prepares the body for labor, progesterone is the primary hormone responsible for preventing premature contractions and maintaining the pregnancy.

B. hCG​

Human chorionic gonadotropin (hCG) is essential for early pregnancy, as it helps maintain the corpus luteum, which produces progesterone during the early stages of pregnancy. However, its role is temporary, and progesterone takes over as the primary hormone for maintaining pregnancy later.

C. Oxytocin​

Oxytocin is important during labor and delivery as it stimulates uterine contractions, but it is not essential for maintaining pregnancy. In fact, high levels of oxytocin could lead to preterm labor.

Correct Answer

C. Uterine rupture

Explanation

Uterine rupture is a rare but life-threatening complication associated with Pitocin (oxytocin) administration. It results from overstimulation of the uterus, especially in women with previous uterine surgery such as cesarean section. The condition can lead to catastrophic hemorrhage, fetal distress, and requires immediate surgical intervention. Monitoring for signs of excessive uterine activity is crucial to prevent this severe outcome.

Why other options are wrong

A. Maternal hypotension

While maternal hypotension can occur during labor due to various factors, it is not a common or direct adverse effect of Pitocin. This medication is more associated with increased uterine contractility. Hypotension is more typically linked with epidural anesthesia or hemorrhage, not with oxytocin administration.

B. Hypertonic uterine contractions

Hypertonic contractions are a possible side effect of Pitocin and can lead to fetal distress or uterine rupture. However, they are a contributing factor rather than the most serious complication themselves. The most dangerous outcome of uncontrolled hypertonic contractions is uterine rupture, which has more severe implications.

D. Fetal bradycardia

Fetal bradycardia can occur as a result of uteroplacental insufficiency from excessive uterine activity, which may be induced by Pitocin. However, this is a symptom rather than the primary complication. Uterine rupture, in contrast, is a direct, serious maternal complication that can also cause fetal bradycardia as a secondary effect.

Correct Answer

D. Respiratory depression

Explanation

Naloxone is used to reverse the effects of opioid overdose, particularly respiratory depression. After naloxone administration, the nurse should monitor closely for signs of withdrawal or a return of respiratory depression. The effects of naloxone can wear off before the opioid, leading to a possible rebound of respiratory depression. Hence, monitoring for respiratory status is the priority.

Why other options are wrong

A. Cerebral edema

Cerebral edema is not typically a concern with naloxone administration. It is more related to other conditions, such as head trauma or specific neurological diseases, but not a common side effect of opioid antagonists like naloxone.

B. Kidney failure

Kidney failure is not a direct concern when administering naloxone. While opioid overdose can impact renal function, naloxone primarily works to reverse respiratory depression, and kidney failure is not a common result of its use.

C. Seizure activity

Although withdrawal from opioids can cause seizures in some cases, seizures are not a direct effect of naloxone administration. The nurse should be more concerned with the immediate risk of respiratory depression returning after the naloxone wears off, rather than seizures.