6. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
Correct Answer: C
The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. Strict intake and output will be assessed throughout the magnesium sulfate infusion. Record urinary output at least every 1 hour if Foley catheter is in place. Otherwise, measure and record all voids. Urine output should be at least 30 mL/hour while administering magnesium sulfate. If less, notify the provider of decreased urine output.
Option A: There is no need to refrain from checking the blood pressure in the right arm. Before beginning any infusion of magnesium sulfate, the primary RN will obtain baseline vital signs (temperature, pulse, respirations, blood pressure, and O2 saturation). Baseline fetal heart rate (FHR), deep tendon reflexes (DTRs), clonus, bilateral breath sounds, urinary output, and activity will be assessed and documented in the Electronic Health Record (EHR).
Option B: A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Temperature is assessed every 4 hours, unless rupture of membranes. Once membranes have ruptured, temperature will be assessed every 2 hours. If febrile (? 100.4) provider will be notified and temperature will be assessed hourly thereafter.
Option D: Darkening the room is unnecessary. Inform staff and visitors of the need to maintain a quiet environment, and avoidance of excessive visitation and environmental stimulation. Include assessment of epigastric pain, visual disturbances, edema, headache, level of consciousness, and lung auscultation prior to start of infusion and every 2 hours throughout infusion or more frequently as condition indicates.
7. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
Correct Answer: D
If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Appropriate management of such patients entails understanding of ethical and legal issues involved, providing meticulous medical management, use of prohemostatic agents, essential interventions and techniques to reduce blood loss and hence, reduce the risk of subsequent need for blood transfusion.
Option A: It is inappropriate to ask the mother to leave during blood transfusion, especially as she has not consented to it. Respect for patient’s autonomy and human rights require obtaining informed consent before any medical intervention. This is fundamental to good medical practice. The rejection of blood transfusions causes an ethical dilemma between the patient’s freedom to accept or to reject a medical treatment even unto death (i.e., autonomy), and the physician’s duty to provide optimal treatment.
Option B: It is better to discuss with patients the specifics of blood transfusion refusal, if possible. A mentally competent individual has an absolute moral and legal right to refuse or reject the consent for medical treatment or transfusion except when he has diminished decision-making capacity or a legal intervention mandates treatment.
Option C: It is the physician’s primary responsibility to explain the consequences to the mother and try to encourage her to consent for the procedure. It is important to convince that every attempt will be made to avoid blood, but also convey that a doctor would not allow a child to let die for lack of blood transfusion. In the UK, children under 16 years of age can legally give consent if they can understand the issues involved (Gillick Competence).
8. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
Correct Answer: B
The nurse should be most concerned with laryngeal edema because of the area of burn. For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour. One commonly used fluid resuscitation formula is the Parkland formula. The total amount of fluid to be given during the initial 24 hours = 4 ml of LR × patient’s weight (kg) × % TBSA.
Option A: Severe burns cause not only significant injury at the local burn site but also a systemic response throughout the body. Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours peaking at around six to eight hours after injury. This response, along with decreased cardiac output and increased vascular resistance, can lead to marked hypovolemia and hypoperfusion called “burn shock.”
Option C: Patient’s vital signs, mental status, capillary refill and urine output must be monitored and fluid rates adjusted accordingly. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation. Recent literature has raised concerns about complications from over-resuscitation described as “fluid creep.” Again, adequate fluid resuscitation is the goal.
Option D: The primary survey assesses the A.B.C.s for life-threats. In the burn patient, attention should focus on the airway looking for oral burns that might cause swelling and obstruction, breathing problems from smoke inhalation or lung injury, and bleeding or circulation problems by looking for life-threatening bleeding and checking blood pressure, heart rate, and pulses. The next step would be resuscitation and immediate intervention for life-threats.
9. The nurse is evaluating nutritional outcomes for a with anorexia nervosa. Which data best indicates that the plan of care is effective?
Correct Answer: D
The client with anorexia shows the most improvement by weight gain. Expect weight gain of about 1 lb (0.5 kg) per week to see the effectiveness of the treatment regimen. Establish a minimum weight goal and daily nutritional requirements. Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
Option A: Selecting a balanced diet does little good if the client will not eat. Make a selective menu available, and allow the patient to control choices as much as possible. Patient who gains confidence in herself and feels in control of the environment is more likely to eat preferred foods.
Option B: The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition. Use a consistent approach. Sit with the patient while eating; present and remove food without persuasion and comment. Promote a pleasant environment and record intake. Patient detects urgency and may react to pressure. Any comment that might be seen as coercion provides focus on food. When staff responds in a consistent manner, the patient can begin to trust staff responses. The single area in which the patient has exercised power and control is food or eating, and he or she may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with the patient and avoid manipulative games.
Option C: The tissue turgor indicates fluid stasis, not an improvement of anorexia. Maintain a regular weighing schedule, such as Monday and Friday before breakfast in the same attire, and graph results. Provides an accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.
10. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
Correct Answer: D
Paresthesia is not normal and might indicate compartment syndrome. Acute compartment syndrome occurs when there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Acute compartment syndrome is considered a surgical emergency since, without proper treatment, it can lead to ischemia and eventually necrosis.
Option A: At this time, pain beneath the cast is normal. Pain is typically severe, out of proportion to the injury. Early on, pain may only be present with passive stretching. However, this symptom may be absent in advanced acute compartment syndrome. In the initial stages, pain may be characterized as a burning sensation or as a deep ache of the involved compartment.
Option B: Classically, the presentation of acute compartment syndrome has been remembered by “The Five P’s”: pain, pulselessness, paresthesia, paralysis, and pallor. However, aside from paresthesia, which may occur earlier in the course of the condition, these are typically late findings.
Option C: Pulses should be present. Beware that the presence or absence of a palpable arterial pulse may not accurately indicate relative tissue pressure or predict the risk for compartment syndrome. In some patients, a pulse is still present, even in a severely compromised extremity.