Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is:
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Solution
Loose, bloody
Option C: Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
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Solution
A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due
Option C: This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics.
Options A, B, and D: The other patients require assessments and care from RNs more experienced in caring for patients with neurologic diagnoses. Focus: Assignment.
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
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Solution
Transfer to radiology for a CT scan.
Option B: The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated.
Options A, C, and D: The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. Focus: Prioritization
You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
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Solution
The patient does not recognize family members.
Option A: The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated.
Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem.
Options B and D: The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment, but they are not emergencies. Focus: Prioritization
A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. Her husband tells you that he rarely gets a good night’s sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?
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Solution
Caregiver Role Strain related to continuous need for providing care
Option B: The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis.
Option A: There is no evidence that the patient’s cardiac output is decreased. The husband’s statements about how he monitors the patient and his concern with medication administration indicate that the Risk for
Options C and D: Ineffective Therapeutic Regimen Management and falls are not priorities at this time. Focus: Prioritization
As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
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Solution
Check for improvement in resident memory after medication therapy is initiated.
Option A: LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident.
Options B and D: Assessment for changes on the Mini-Mental State Examination and developing the plan of care are RN responsibilities.
Option C: Assisting residents with personal care and hygiene would be delegated to nursing assistants working the LTC facility. Focus: Delegation
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all that apply).
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Solution
Answer: A, C, and E
Options A, C, and E: NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists. Evaluation of patient response to medication and development and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation
After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
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Solution
A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain
Option D: Urinary tract infections are a frequent complication in patient with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly.
Options A, B, and C: The other patients should be assessed soon, but do not have needs as urgent and this patient. Focus: Prioritization
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
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Solution
The white blood cell count is 2300/mm3.
Option B: Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication.
Options A, C, and D: The other data indicate a need for further assessment and/or patient teaching, but will not require a change in medical treatment for the seizures. Focus: Prioritization
While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?
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Solution
Turn the patient to the side and protect airway.
Option C: The priority action during a generalized tonic-clonic seizure is to protect the airway.
Option B: Administration of lorazepam should be the next action, since it will act rapidly to control the seizure.
Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea.
Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. Focus: Prioritization