Care Exam 2 Notes

MEDICATION ADMINISTRATION (chap.
35)
 Medication legislation and standards
o Federal regulations- role is to protect the health of the people by ensuring that
medication are safe and effective
 Food and drug administration- current enforcers that ensure all
medications undergo vigorous testing before going public
o State and local regulation- these laws must conform to federal legislation, often
have additional controls, including control of substances not regulated by federal
government (alcohol, tobacco)
o Health care institutions and medication laws- health care industries can establish
their own policies to meet federal, state, and local regulations.
o Medication regulations and nursing practice-
 state Nurse Practice Acts have the most influence over nursing practice by
defining scope of nurses professional functions and responsibilities. Primary
intent of NPA is to protect the public from unskilled, undereducated and
unlicensed personnel
 Pharmacological concepts
o Drug names- can be the chemical name (N-acetyl-para-aminophenol), generic
name (acetaminophen) and trade name (Tylenol)
o Classification- indicates the effect of medication on body system, symptoms the
medication relieves, or desired effect. Usually each class contains more than one drug
listed for same health problem
o Medication forms- tablets, capsules, elixirs and suppositories
 Pharmacokinetics as basis of medication action
o Absorption- the passage of medication molecules into blood from site of
medication administration
 Route
 Ability of medication to dissolve
 Blood flow to site of administration
 Body surface area
 Lipid solubility of medication
o Distribution- med. Is distributed to body tissues and organs and specific sites,
depends on
 Circulation
 Membrane permeability
 Protein binding
o Metabolism- after medication reaches site it is metabolized into less
active/inactive form that is easier to excrete.
 The kidneys, liver, lungs, blood and intestines metabolize medications.
 If client has problem with an organ that metabolizes medications then the
client is at risk for medication toxicity
o Excretion- exit the body through kidneys, liver, bowel, lungs, and exocrine
glands.
 Chemical makeup up med determines its excretion route
 Kidneys are main organ for excretion
 Types of medication action
o Therapeutic effects- predictable phsyiological response a medication causes.
 Knowing desired therapeutic effect for each medication allows the nurse
to provide client education and accurately evaluate medications desired effect
o Side effects/adverse effects - side effects are predictable while adverse effects are
unintended
 Toxic effects- when medication accumulates in blood due to impaired
metabolism or excretion
 Idiosyncratic- unpredictable effects (child takes benadryl and instead of
becoming drowsy they become hyper or agitated)
 Allergic reactions- unpredictable responses, some clients can become
sensitized to medication and develop allergic response to medication.
 Routes of administration-
o Oral- easiest and most common
 Sublingual- drugs are absorbed under the tongue (nitroglycerin)
 Buccal- solid medication placed in mouth against the mucous membrane
of cheek.
o Parenteral- injections
 Intradermal (ID)- inject into the dermis, just under the epidermis
 Subcutaneous (sub-Q)- inject into tissue below dermis
 Intramuscular (IM)- inject into muscle
 Intravenous (IV)- inject into vein
 Some are administered to other body cavities
 Epidural- epidural space via catheter
 Intrathecal- catheter in subarachnoid space or into one of the
ventricles of brain.
 Intraosseous- infusion of meds directly into bone marrow
(commonly used in emergencies when IV access is impossible)
 Intraperitoneal- administered in the peritoneal cavity and absorbed
by ciculation
 Intrapleural- injection or chest tube directly into pleural space
 Intrarterial- administered directly into arteries
o Topical- applied to skin and mucous membranes
o Inhalation- readily absorbed and work rapidly
o Intraocular- inserting medication similar to contact lens into the eye

Nursing Knowledge base
 Know clinical calculations
 Prescribers role - prescribers must document the diagnosis, condition, or need for use for
EACH medication ordered.
 Types of orders in acute care agencies
o Standing orders- carried out until prescriber cancels it or until prescribed number
of days elapse. Often has final date or number of doses
o Prn orders- given only when client needs it. Use objective and subjective
assessment in determining whether or not the client needs it.
o Single-(ex: valium before a surgery)
o STAT - single dose of med is to be given immediately
o Now orders- when client needs a medication quickly but not right away. Nurse
has up to 90 minutes to administer.
o Prescriptions- taken out of hospital
 Distribution systems
o Unit dose- use carts with drawer of 24 hour supply for each client. Cart is filled
by pharmacist or pharmacy tech.
o Automated medication dispensing system- control the dispensing of meds
including narcotics. Clients name is pulled up then the med is pulled out, charging that
med to that client.
 Medication errors
o Steps to take
 Follow 6 rights of med administration
 Read labels at least 3 times
 Use at least 2 client identifiers
 Allow no interruptions
 Double check calculations
 Don’t interpret illegible handwriting; clarify with prescriber
 Question unusually large or small doses
 Document all meds AS SOON as they are given
 If error is made reflect what went wrong
 Evaluate context or situation error occurred
o Medication reconciliation- comparison of all meds current meds with previous
setting
VERIFY- obtain current list of clients meds
CLARIFY- make sure list of med, dosages and frequencies is accurate, clarify
with others
RECONCILE- compare new med orders with current list; investigate
discrepancies
TRANSMIT- communicate the updated and verified list to caregivers and client
Critical thinking
 Knowledge- know why physician prescribed med and how med will alter clients
physiology to have therapeutic effect
 Experience
 Attitudes- through discipline you take adequate time to prepare and administer meds.
 Standards- be aware of hospitals limitations and follow the 6 rights
o Right medication- compare prescribers order with MAR, verify med information
whenever new MARs are written, or pt transfers. When verified it is accurate, then use
the MAR to prepare and administer. Compare the label of medication with MAR 3
times.
o Right dose- have another qualified nurse check calculations, use graduated cups,
syringes, and scaled droppers to measure accurately
o Right client- use 2 client identifiers, these include the clients name, identification
number, or telephone number
 In acute setting you can use the MAR with client identification while at
bedside
 The TJC does not require clients to state their names and other identifiers
when administering meds, you can use this once they are admitted (with
wristband)
o Right route-
o Right time- know why a medication is ordered for certain times of the day and if
it can be altered at all.
o Right documentation- ensure accurate and appropriate documentation exists
before and after giving meds.
 Before administering ensure that documentation in MAR clearly reflect
clients full name, the name of ordered med written in full form, the time med is to
be given, and meds dosage, route and frequency.

Nurses have 6 rights for safe medication administration
o Right to a complete and clearly written order
o Right to have correct drug route and dose dispensed
o Right to have access to information
o Right to have policies on medication administration
o Right to administer medication safely and to identify problems
o Right to stop, think, and be vigilant

o Maintaining clients rights...
 Right to be informed of medications name, purpose, action and potential
undesired effects
 To refuse medication regardless of consequences
 To have qualified nurses and physicians assess a medication hx
 To be properly advised of experimental nature of med therapy
 To receive labeled medications safely without discomfort in accordance
with 6 rights of med administration
 To not receive unnecessary medications
 To be informed if medication are a part of research study

NURSING PROCESS AND MEDICATION ADMINISTRATION
 Assessment
o Obtain or review clients medical hx
o Hx of allergies-
o Medication data- assess information about each medication client takes, including
how long they have been taking it, current dose, and whether or not client experienced
adverse effects.
o Diet hx- this reveals normal eating patterns and food preferences to allow the
nurse to plan the dosage schedule more effectively and teaches client to avoid foods
that will interact with meds
o Clients perceptual/coordination problems- assess clients ability to prepare doses
and take medications correctly
o Clients current condition- assess a client carefully before giving any medication!
o Clients attitude about medication use- observe clients behavior for evidence of
medication dependence or avoidance
o Clients knowledge and understanding of medication therapy
o Clients learning needs
 Diagnosis
o Select the dx then identify the related factors. Diagnosis in med administration
could be
 Anxiety, ineffective health maintenance, health seeking behaviors,
deficient knowledge, noncompliance, disturbed visual sensory perception…
 Planning
o Goals and outcomes
 Ex: Goal- the client will safely administer all ordered medications before
discharge.
 Outcomes- client with verbalize understanding of desired effects and
adverse effects of medication
 The client will state s/s and treatment of hypoglycemia
 Client will be able to monitor blood glucose level
o Set priorities-
o Collaborative care
 Implementation
o Health promotion- teach the client and family about the benefits of a medication
and the knowledge needed to take it correctly, and integrate clients health beliefs and
cultural practices into treatment plan.
o Acute care- when med order is received many interventions are essential for safe
and effective med administration.
 Ensure med order contains…
 Clients full name
 Date and time order is written
 Medication name
 Dose
 Route of administration
 Signature of physician, NP, or PA
 Correct transcription and communication of orders
 Accurate dose calculation and measurement
 Correct administration- use aseptic techniques and proper
procedures when handling meds
 Record medication administration IMMEDIATELY on appropriate
record form
 Evaluation
o Monitor clients response on an ongoing basis

Review purple pages to learn how meds can be administered.

Safe and accurate administration of medications is one of your most important
responsibilities. You are responsible for understanding the following about
medications:
 Expected actions
 Dosage
 Desired effects and/or purpose
 Possible adverse reactions
 Interactions
 Contraindications
 Precautions
 Pharmacokinetics

Mechanism of Action

When a medication is administered to a client, a predictable chemical reaction

changes the physiologic activity of the body. This most commonly occurs when
a medication bonds chemically to a specific site called a receptor site. These
reactions are possible only when the receptor site and the chemical fit together
like a key in a lock.
When the chemical fits well, the chemical response is good. We call these
medications agonists.
Some medications attach at the receptor site without producing a new chemical
reaction. These medications are called antagonists.
Other medications attach and produce only a small response or prevent other
reactions from occurring. These medications are called partial agonists.

Peak and Troughs

The therapeutic levels of certain medications, such as antibiotics, can be
monitored by laboratory tests:
 The lowest serum level is the trough level. Blood samples for trough
levels are usually drawn 30 minutes before the medication is administered.
 The highest serum concentration or peak concentration of medication
usually occurs just before the last of the medication is absorbed.
 Blood samples for peak levels are drawn to coincide with the time that
the medication is expected to reach its peak concentration. This varies with
medication pharmacokinetics.
 Precise coordination with the laboratory is essential for drawing blood
specimens for the peak and trough levels on time and thus obtaining
meaningful information. These data allow physicians to modify medication
dosages.

Safe Medication Administration Pre-Procedure Preparation
• Before you begin: Use good medical aseptic technique.
o Perform hand hygiene before preparing a dose of medication and
before administering it.
o Wear clean gloves if there is a chance of contacting body fluids.
o Avoid touching tablets and capsules.
o Use sterile technique for parenteral medications.
• Identify your client by inspecting the ID bracelet and asking the client to
state his or her name.
• Explain what you will be doing and why, which should resolve any
concerns and fears that your client has about what you are going to do.
• If appropriate, provide privacy.

6 RIGHTS OF MEDICATION ADMINISTRATION

6 Rights for Administration of Medication
Right Client: The right client can be ensured by verifying that the medication
record and the client wristband agree. This means that the client's name, health
care provider's name, and the client's facility number are the same on both. You
also verify the "right client" by asking the client to state his or her name. Two
identifiers (e.g., comparing the MAR to the client's ID bracelet and asking the
client to state name) are required to identify the client (neither identifier can be
the client's room number) when administering medications (JCAHO, 2004).
Right Drug: The right medication can be ensured by reading the label or
medication form carefully three times:
 When picking up the medication or bottle
 Just before preparing the medication for dispensing
 Before either throwing the unit-dose package away or before putting
the bottle back in the drawer or cupboard where it is stored
You must know the use of the specific medication and the expected dosage
ranges and compare these to the client's health conditions being treated and
the dosage ordered. If at any time you identify an incorrect spelling of a
medication name, a medication label that fails to match the order or is
unreadable, or a dosage outside the accepted range for that medication, you
should clarify the order with either the pharmacy that dispensed the medication
or the health care provider who ordered the medication. This aspect of the "6
rights" cannot be emphasized enough. Many medication errors could be avoided
with full adherence to this step in administering medications.
Right Dose: Check the right dose by looking the medication up in a drug
reference. If the medication is relatively new to the market and unavailable in a
drug reference, check with the pharmacy that dispensed the medication. The
pharmacy will have the information you need to ensure the correct medication
in the correct dosage. If you note a discrepancy between the recommended
dose and the dose ordered, you must contact the pharmacy that dispensed the
medication or the health care provider that ordered the medication. You must
be able to calculate, accurately, the correct dosage to be given.
Right Time: The right time for administration involves administering the
correct medication in the correct dose within the acceptable time frame. Once
medication administration is started, the goal is to maintain therapeutic serum
levels of the medication. In most instances, the medication can be considered
given "on time" if administered within one-half hour before to one-half hour
after the time the medication is ordered to be given.
Right Route: The right route refers to the route by which the medication is to
be administered. If a prescriber's order does not designate a route, or if the
route is not the recommended one, you must consult the prescriber.
Right Documentation: The right documentation refers to the charting of the
time that the medication is given as soon as possible after the medication has
been administered. This documentation should be placed on the MAR under the
correct date and time.

Common Dosage Administration Schedules
Dosage Schedule Abbreviation
Before meals AC, ac
As desired ad lib
Twice a day BID, bid
Hour h
At bedtime hs (hour of sleep)
After meals PC, pc
Whenever there is a need prn
Every morning, every am Qam
Every day, daily daily
Every hour Qh
Every 2 hours q2h

Every 4 hours q4h
Every 6 hours q6h
Every 8 hours q8h
4 times a day QID, qid
Every other day every other day
Give immediately STAT
3 times a day TID, tid

MEDICATION ADMINISTRATION

1. The nurse is having difficulty reading a physician's order for a medication. The nurse knows the
physician is very busy and does not like to be called. The nurse should:
A) Call a pharmacist to interpret the order.
B) Call the physician to have the order clarified.
C) Consult the unit manager to help interpret the order.
D) Ask the unit secretary to interpret the physician's handwriting.

It is the nurse's responsibility to ensure that the medication orders are correct. Asking a unit manager
or pharmacist to help interpret an order is always helpful, but the nurse is still responsible. A unit
secretary can help with reading handwriting, but the nurse is still responsible.Points Earned: 1.0/1.0
Correct Answer(s): B

2. The client has an order for 2 tablespoons of milk of magnesia. The nurse converts this dose to the
metric system and gives the client:
A) 2 ml
B) 5 ml
C) 16 ml
D) 30 ml
Each teaspoon is 5 ml and 2 tablespoons is 6 teaspoons, so 5 × 6 = 30 ml.Points Earned: 1.0/1.0

Correct Answer(s): D

3. Most medication errors occur when the nurse:
A) Is caring for too many clients
B) Fails to follow routine procedures
C) Is administering unfamiliar medications
D) Is responsible for administering numerous medications

Medication errors occur most often when the nurse fails to follow the routine procedures that are in
place to ensure client safety. The other options are not correct if the nurse follows the protocols.Points
Earned: 0.0/1.0

4. A client is to receive cephalexin (Keflex) 500 mg by mouth. The pharmacy has sent 250-mg tablets.
The nurse gives:
A) ½ tablet
B) 1 tablet
C) 1½ tablets
D) 2 tablets

Two 250-mg tablets = 500 mg.Points Earned: 1.0/1.0

5. When identifying a new client before administering medications, the nurse asks the client to state
his name. The client does not give the correct name. The nurse asks again and the client states still
another name. What is the nurse's next action?
A) Laugh at the client and tell him to "quit kidding."
B) Give the medications without any further questioning.
C) Investigate the client's mental status before administering any further medications.
D) Look at the client's arm band to identify the client and disregard what the client said.

The ongoing physical and mental status of a client affects whether a medication is given or how it is
administered. The client should be assessed carefully before administering any medication. The nurse
should always check the client's arm band to ensure that this is the correct client for the given
medication, even if the client responds with the correct name. The client should always be identified
using at least two identifiers before administering medication, preferably by comparing the client
identifiers on the MAR with the client's arm band at the bedside.Points Earned: 1.0/1.0
Correct Answer(s): C

6. A client is transitioning from the hospital to the home environment. A home health referral has been
obtained. In terms of safe medication administration, what is a priority for the discharge nurse?
A) Set up the follow-up physician appointments for the client.
B) Ensure that someone will provide housekeeping for the client at home.
C) Make sure that the client has plenty of diapers and blue pads to take home.
D) Ensure that the home health care agency is aware of medication and health teaching needs.

The home care agency should be aware of the medication and health teaching needs of all clients. The
other options are issues that should be addressed, but the question is specifically asking regarding safe
medication administration, so this answer is the only one that answers the question correctly.Points
Earned: 1.0/1.0

7. A nursing student takes a client's antibiotic to his room. The client asks the nursing student what it is
and why he should take it. The nursing student should:
A) Inform the client that only the client's physician can give this information.
B) Provide the name of the medication and a description of its desired effect.
C) Tell the client that information about medications is confidential and cannot be shared.
D) Explain that, because of the limits placed on nursing students, the client will have to speak with his
assigned nurse about this.

The nursing student should know the name, dose, and purpose of all medications that he or she is
responsible for administering. Part of client teaching is sharing this information with the client, so the
student should be able to verbalize this information to the client. This information is not confidential,
and the student nurse should present this information without waiting for a physician or the client's
assigned nurse.Points Earned: 0.0/1.0

8. The nurse is administering a sustained-release capsule to a new client. The client insists that he
cannot swallow pills. The best course of action for the nurse is to:
A) Ask the physician to change the order.
B) Crush the pill with a mortar and pestle.
C) Hide the capsule in a piece of solid food.
D) Open the capsule and sprinkle it over pudding.

Sustained-release medications should never be crushed or sprinkled on food. Hiding the capsule in a
piece of solid food is not an appropriate nursing step. The nurse should contact the physician for an
order change.Points Earned: 0.0/1.0
Correct Answer(s): A

9. The nurse selects the route for administering medication according to:
A) Hospital policy
B) The prescriber's orders
C) The type of medication ordered
D) The client's size and muscle mass

Facilities have protocols for medication administration that the nurse must follow. If a physician's order
contradicts the protocols, then the order must be clarified with the physician and the protocol
explained. The protocol will include specifics for the type of medication ordered and the client's size and
muscle mass.Points Earned: 0.0/1.0

10. A client is receiving an intravenous (IV) push medication. If this type of drug infiltrates into the
outer tissues the nurse will:
A) Continue to let the IV run.
B) Apply a warm compress to the infiltrated site.
C) Follow facility policy or the drug manufacturer's directions.
D) Not worry about this because vesicant filtration is not a problem.

The infusion of the medication should be halted and the facility policy or drug manufacturer's directions
followed. Infiltration of some medications will create no harm. For others, harm can be averted by the
application of warm compresses. Still others may require other treatments if infiltration occurs.Points
Earned: 0.0/1.0

11. If a client who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain
at the site, the nurse suspects
A) Sepsis.
B) Phlebitis.
C) Infiltration.
D) Fluid overload.

Warmth, redness, and tenderness of an IV site indicate phlebitis. Infiltration usually presents as a cool,
swollen, and pale IV site. Sepsis is an infection, and signs of sepsis may or may not be present at the site.
Fluid overload will not produce specific changes at the IV site.Points Earned: 0.0/1.0

12. A nurse administering medications has many responsibilities. Among these responsibilities is a
knowledge of pharmacokinetics. Which statement is the best description of pharmacokinetics?
A) The passage of medication molecules into the blood from the site of administration
B) The degree to which medications bind to serum proteins, which affects distribution
C) The study of how medications enter the body, reach their site of action, metabolize, and exit the body
D) The method by which a medication, after absorption, is moved within the body to tissues, organs, and
specific sites of action

Pharmacokinetics is the study of how medications enter the body, travel to the site of action,
metabolize, and exit the body. Distribution refers to the method by which medication, after absorption,
is moved within the body. Absorption is the passage of medication molecules into the blood from the
site of administration. The degree to which medications bind to serum protein is protein binding.Points
Earned: 0.0/1.0

13. A nurse provides a medication to a client. Who has the ultimate responsibility for the medication
that is being administered?
A) The client taking the medication
B) The nurse administering the medication
C) The pharmacist providing the medication
D) The physician, advanced practice nurse, or physician's assistant prescribing the medication

The nurse does not have sole responsibility for medication administration. However, the nurse
administering the medication is accountable for knowing which medications are prescribed for the
client, their therapeutic and nontherapeutic effects, the nursing implications, and the level of the client's
knowledge. The prescriber and the pharmacist also help to ensure the right medication gets to the right
client.Points Earned: 0.0/1.0

14. The following orders were written by a prescriber (physician, advanced practice nurse, physician's
assistant). Which order is written correctly?
A) Aspirin 2 tablets prn
B) Haloperidol (Haldol) ½ tablet at bedtime
C) Zolpidem (Ambien) 5 mg PO at bedtime prn
D) Levothyroxine (Synthroid) 0.05 mg 1 tablet

The order for zolpidem is the only medication order that contains the essential components of a drug
order—name of medication, dose, route of administration, and frequency.Points Earned: 0.0/1.0

15. To better control the client's blood glucose level, the physician orders a high regular insulin dosage
of 20 units of U-500 insulin. The nurse has only a U-100 syringe. How many units will be given?
A) 4
B) 5
C) 10
D) 20

U-500 insulin is 5 times as strong as U-100 insulin. Therefore the amount of U-500 insulin should be
divided by 5; 20 units ÷ 5 = 4 units.Points Earned: 0.0/1.0

16. The nurse is administering an intramuscular (IM) injection. The Z-track method is recommended for
IM injections because:
A) It is easier for the nurse to use.
B) It allows for repeated injections into the same site.
C) It does not require the nurse to aspirate before injecting the medication.
D) It minimizes local skin irritation by sealing the medication in muscle tissue.
The Z-track method minimizes local skin irritation, providing more comfort for the client. Repeated
injections in the same muscle can cause severe discomfort and poor absorption. The Z-track method of
injection is not easier but requires practice by the nurse to achieve a smooth injection technique
because of the increased number of steps in the method. Aspiration is still required when the Z-track
method is used.Points Earned: 0.0/1.0

17. What is the best nursing practice for administrating a controlled substance if part of the
medication must be discarded?
A) The nurse documents on the medication administration record.
B) The nurse discards the unused portion and documents on the control inventory form.
C) The nurse does not discard any controlled substance to prevent environmental contamination.
D) The nurse documents on the medication administration record and the control inventory form, and
has a second nurse witness the medication being discarded.

The nurse signs both records and has a second nurse witness the discarding of the controlled substance
and also sign the control inventory form. Agency policy dictates how the substance is discarded to avoid
environmental concerns.Points Earned: 0.0/1.0

18. When administering medications, it is essential for the nurse to have an understanding of basic
arithmetic to calculate doses. The physician has ordered 250 mg of a medication that is available in 1-g
amount. The vial reads 2 ml = 1 g. What dose would be given by the nurse?
A) 0.25 ml
B) 0.5 ml
C) 1 ml
D) 2.5 ml

0.5 ml = 250 mg of this medication.
(Dose ordered/dose on hand) × amount on hand = amount administered
[250 mg/1000 mg (1 g)] × 2 ml = 500/1000 = ½ ml or, in decimals, 0.5 mlPoints Earned: 0.0/1.0

19. While the nurse is administering medication, the client says, "This pill looks different from what I
usually take." What is the nurse's best action?
A) Go recheck the medication order, taking along the medication.
B) Ignore the statement because the client has a history of confusion.
C) Leave the medication at the bedside and go recheck the order.
D) Tell the client that pill manufacturers often change the color of pills.

This is a safety issue and should not be ignored. Leaving the medication at the bedside is an unsafe
practice and does not demonstrate the nurse's responsibility. If checking the medication order does not
clarify the situation, then the nurse should check with the pharmacist regarding pill shape, color, and so
on. Different manufacturers will design their own brands to look different from their competitors'
brands. Checking the client's statement can avoid a potential medication error, and the client
appreciates the efforts of the nurse.Points Earned: 0.0/1.0

20. The client is a 40-year-old man who weighs 160 lb and is 5 feet 9 inches tall. The order is for 5 ml of
a medication to be given as a deep intramuscular (IM) injection. What size of syringe and gauge and
length of needle should the nurse use for best practice?
A) One 5-ml syringe, 20- to 23-gauge 1-inch needle
B) Two 2-ml syringes, 25-gauge 1-inch needle
C) Two 3-ml syringes, 23-gauge, ½-inch needle
D) Two 3-ml syringes, 20- to 23-gauge, 1½-inch needle
A medication dose of 5 ml administered IM is unlikely to be absorbed properly. Therefore, dividing the
dose is correct. Dividing the doses equally allows 2.5 ml to be given in two different sites, so the nurse
will need two 3-ml syringes. A deep IM injection must pass through subcutaneous tissue and penetrate
deep muscle; therefore the needle must be long enough (1½ inch) and the gauge heavy enough (20 to
23 is the best choice).Points Earned: 0.0/1.0

21. A site that was a traditional location for intramuscular (IM) injections in the past is no longer
recommended because its use carries the risk of striking the underlying sciatic nerve or major blood
vessel. What is the name of this site?
A) Plexor
B) Dorsogluteal
C) Ventrogluteal
D) Vastus lateralis

The dorsogluteal is the not-so-safe traditional site. The ventrogluteal muscle is situated deep and away
from major nerves and blood vessels. The vastus lateralis muscle is thick and well developed. The plexor
is the middle finger of the dominant hand used during percussion or a percussion hammer used to strike
the pleximeter and is not related to IM sites.Points Earned: 0.0/1.0
ACTIVITY AND EXERCISE (chap. 37)

Principals of safe client transfer and positioning
 When client is able to assist…
o The wider the base of support, the greater your stability
o The lower the center of gravity, the greater your stability
o The equilibrium of an object is maintained as long as the line of gravity passes through
its base support
o Facing the direction of movement prevents abnormal twisting of the spine
o Dividing balanced activity between arms and legs reduces the risk of back injury
o Leverage, rolling, turning, or pivoting requires less work than lifting
o When friction is reduced between the object to be moved and the surface on which it is
moved, less force is required to move it.

Nursing process
Assessment:
 Assess the clients body alignment (standing and sitting), posture, and mobility (ROM, gait)
 Identify the impact of activity and exercise pattern on clients overall level of health
 Assess clients routine exercise pattern
 Observe the clients body systems' response to activity and exercise

Diagnosis:
 Examples of nsg dx.- activity intolerance, ineffective coping, impaired gas exchange, risk for
injury, impaired physical mobility, imbalanced nutrition, acute or chronic pain.

Planning:
 Consult/collaborate with members of health care team to increase activity
 Involve the client and family in designing an activity and exercise plan
 Consider clients ability to increase activity level

Implementing:
 Health promotion- promotion of engagement in exercise routine
 Body mechanics-teach proper technique with assistive equipment, and body mechanics
 Acute care-
o Musculoskeletal system- encourage stretching and isometric exercise
o Join mobility- ROM exercises
o Walking
o Helping client to walk
 Restorative and continuing care
o Assistive devices for walking
o Walkers
o Canes
o Crutches- teach the client….
 not to lean on crutches
 About the dangers of pressure on axillae
 Explain why clients need to use crutches that were measured for them
specifically
 Show client how to routinely inspect crutch tips
 Explain the crutch tips need to remain dry
 Show client how to inspect the structure of crutches
Some of the conditions that oxygen therapy is used for include:
 documented hypoxemia
 severe respiratory distress (e.g., acute asthma or pneumonia)
 severe trauma
 acute myocardial infarction
 short-term therapy, such as post-anesthesia recovery

OXYGENATION

1. Apply knowledge of normal anatomy and physiology of the respiratory system.
 Nasal cannula
 1-6 L/min; 24-44% oxygen delivered
 Simple face mask

 5-10 L/min; 30-60& oxygen delivered
Applying a Nasal Cannula or an Oxygen Mask
o Clients with sudden changes in their vital signs, level of consciousness, or behavior are
often experiencing profound Hypoxia.
 Inspect client for signs and symptoms associated with hypoxia and presence of
airway secretions.
 Left untreated, hypoxia produces cardiac dysrhythmias and death.
Presence of airway secretions decreases effectiveness of oxygen therapy.
 Obtain clients most recent Sp02 or ABG value.
 Gives baseline to compare outcome of 02 therapy
 Explain to client and family what is happening
 Decreases anxiety and increases cooperation
 Perform Hand Hygiene
 Reduces transmission of infection
 Attach nasal cannula to into clients nares, adjust elastic, attach to humidified
O2 source, adjust to prescribed flow rate.
Prevents drying of the nasal and oral mucosa and airway secretions
 Place tips in the nares, adjust headband, until it is snugly fit and comfortable. If
using an O2 mask, adjust elastic headband until mask fits comfortably over the
clients face and mouth
 Maintain sufficient slack on O2 tubing, and secure to clients clothes.
 Allows client to turn head without dislodging.
 Check cannula every 8 hours or with changes in clients cardiopulmonary status.
Keep humidification jar filled at all times.
 Ensures patency and of cannula and O2 flow. Prevents inhalation of
dehumidified O2
 Observe clients nares and superior surface of both ears for skin break down.
 O2 therapy causes drying of the nasal mucosa. Pressure on ears from
cannula or tubing or elastic causes skin irritations.
 Check O2 flow rate and Physicians orders at least every 8 hours or with changes
in the clients Cardiopulmonary status.
 Ensures delivery of prescribed O2 flow rate and patency of cannula
 Inspect client for relief of symptoms associated with hypoxia.
 Indicates that hypoxia was corrected or reduced.
 Venturi mask
 Non-rebreather mask

Appropriate nursing interventions for the patient receiving oxygen therapy.
Nursing Interventions
 NO SMOKING, sparks or igniting agents
 Oral care & humidification
 Assess/prevent oxygen toxicity
o Prolonged high percentage oxygen causing cell damage
 Monitor dosage of oxygen delivered
 Patient teaching: care and cautions

Procedure for using a pulse oximeter.
 A pulse oximeter permits the indirect measurement of oxygen saturation. It is a probe
light with a LED and a photodetector connected by a cable to an oximeter. Oxygenated and
deoxygenated Hg molecules absorb light differently. It detects the amount of O2 bound to the
Hg molecules. It measures (Sp02) Pulse Oxygen Saturation.
 Oxygen saturation
 Noninvasive technique that measures continuous oxygenated hemoglobin in arterial blood
 Less expensive
 Clean, dry, warm finger, ear lobe, toe; remove every 2hrs for skin care
 Remove nail polish, artificial nails select alternative site
 Range 95 – 100%

Differentiate between the different types of artificial airways.
 Oropharyngeal airway
 Measurement important
o Measure distance from the corner of the mouth to the angle of the jaw below
the ear
o Insert with curved tip upward toward roof of mouth then rotate to move
tongue
 Nasopharyngeal airway
 Measurement same as oropharyngeal


Reasons for Chest Tubes

 Pleural space is incised
 Trauma, Surgery, Disease process, spontaneous
 Atmospheric air enters pleural space
 Negative pressure changes to a positive pressure
 Lung collapses

Purposes
 Remove air &/or fluids from pleural space
o Pneumothorax
o Hemothorax
 Prevent air or fluid from reentering

 Reestablish normal pressures

Prioritize nursing actions appropriate for a patient with a chest tube(s)
Nursing Interventions
 Assist (ONLY!) with insertion & removal - is pain medication important during this
procedure?
 Assess chest drainage
 Observe for bubbling
o Intermittent
o Continuous
o Rapid/Excessive
 While chest tube in place
o Monitor respiratory status & vital signs
o Check dressings
o Maintain patency & integrity of system
o Do not empty drainage system
 Removal of chest tube
o Lung reexpanded
o Verified by chest x-ray, auscultation
 Pleural Drainage
o 3 Compartments
 Collection Chamber, receives fluid and air from chest cavity. Fluid
stayes in this chamber while air moves to the second chamber
 Water-seal chamber, contains 2 cm of H2O, which acts as a one way
valve. The incoming air enters from the collection chamber and bubbles up from
the water. The air then exits the water-seal and enters the suction control
chamber
 Suction control chamber, applies controlled suction to the chest
drainage system. When the negative pressure generated by the suction source
exceeds the 20 cm, air from the atmosphere enters the chamber vent on top and
the air bubbles up through the water.

Plan, implement, and evaluate nursing care of the patient with a chest tube(s) in terms of:

Assessment of respiratory status.
 Assess respirations, presence of chest pain, breath sounds over affected area
 S/S of increased respiratory distress and or chest pain.
 Marked cyanosis, asymmetrical chest movements, hypotension, tachycardia
 Vital Signs and SpO2
 Comfort level
Ensuring proper function of the closed chest drainage system.
 Check chest tube dressing and site of surrounding tube insertion.
 Apply clean gloves if drainage is present
 Keep chest drainage system upright and below level of insertion or you will get backflow
into chest.
Assessing level of fluid drainage.
 Note amount of drainage in system.
Maintaining patency of the chest tube(s)
 Check tubing for kinks, dependent loops of knots

Position client in Fowlers position to evacuate Air

High-Fowlers to drain fluid.
EVOLVE QUESTIONS
1.
A person who starts smoking in adolescence and continues to smoke into middle age:
A) Has an increased risk for alcoholism
B) Has an increased risk for obesity and diabetes
C) Has an increased risk for stress-related illnesses
D) Has an increased risk for cardiopulmonary disease and lung cancer

Feedback: INCORRECT
The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker.
Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled
nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood
pressure and decreasing blood flow to peripheral vessels.
Points Earned: 0.0/1.0
2.
Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of
blood by:
A) Forming a weak bond with hemoglobin
B) Forming a strong bond with hemoglobin
C) Forming a weak bond with carbamino compounds
D) Forming a strong bond with carbamino compounds

Feedback: INCORRECT
CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of
blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a
functional anemia. Because of the strength of the bond, carbon monoxide does not easily
dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.

3.
Conditions such as shock and severe dehydration resulting from extracellular fluid loss
cause:
A) Hypoxia
B) Hypovolemia
C) Hypervolemia
D) Uncontrolled bleeding

Feedback: INCORRECT
Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced
circulating blood volume (hypovolemia).
4.
Fever increases the tissues' need for oxygen, and as a result:
A) Metabolic demands decrease
B) Blood glucose stores stabilize
C) Carbon dioxide production increases
D) Carbon dioxide production decreases

Feedback: INCORRECT
Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production
increases. When fever persists, the metabolic rate remains high and the body begins to
break down protein stores, which results in muscle wasting and decreased muscle mass.
5.
Left-sided heart failure is characterized by:
A) Increased cardiac output
B) Lowered cardiac pressures
C) Decreased functioning of the left atrium
D) Decreased functioning of the left ventricle

Feedback: INCORRECT
Left-sided heart failure is an abnormal condition characterized by decreased functioning of
the left ventricle. If left ventricular failure is significant, the amount of blood ejected from
the left ventricle drops greatly, which results in decreased cardiac output.

6.
Cyanosis, the blue discoloration of the skin and mucous membranes caused by the
presence of desaturated hemoglobin in capillaries, is:
A) A late sign of hypoxia
B) An early sign of hypoxia
C) A sign of a non–life-threatening condition
D) A reliable measure of oxygenation status

Feedback: INCORRECT
Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of
desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of
cyanosis is not a reliable measure of oxygen status.
7.
A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions
and decreased chest wall expansion is:
A) Administration of antiinfectives
B) Chest physiotherapy
C) Oxygen humidification
D) Frequent change of position

Feedback: INCORRECT
Changing the client's position frequently is a simple and cost-effective method for reducing
the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest
wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are
all helpful, but are not cost effective.
8.
The nurse is concerned when a client's heart rate, which is normally 95 beats per minute,
rises to 220 beats per minute, because a rate this high will:
A) Exhaust the client
B) Decrease metabolic rate
C) Reduce coronary artery perfusion
D) Provide too much blood flow to major organs

Feedback: INCORRECT
Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When
the heart rate is elevated, more time is spent in systole and less in diastole; hence, the
myocardium may not be perfused adequately. The client may be exhausted, but the
primary concern is myocardial perfusion. Major organs will adjust to increased blood flow.
This is usually not a problem. With a heart rate this high, metabolic rate will be increased,
not decreased.
9.
A client is admitted to the emergency department with a suspected cervical spine fracture
at the C3 level. The nurse is most concerned about the client's ability to:
A) Breathe
B) Ambulate
C) Maintain cardiac output
D) Be oriented to person, place, and time

Feedback: INCORRECT
Spinal cord injury at the level of C5 or above often results in damage to the phrenic nerve,
which innervates the diaphragm and permits breathing. Cardiac output is not usually
affected by spinal cord injury; however, cardiac output may be reduced as a result of
trauma and blood loss. It is too early to be concerned with ambulation. Life-threatening
problems take priority. Level of consciousness is certainly an important consideration,
because this client most likely sustained a head injury. However, this is not a certainty
given the data provided.

10.
When suctioning secretions that are collecting in an endotracheal tube, the nurse does not
apply suction for longer than:
A) 5 seconds
B) 10 seconds
C) 15 seconds
D) 20 seconds

Feedback: INCORRECT
Applying suction for too long can result in complications such as hypoxemia and cardiac
dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is
applied to an airway. If the suctioning time is too short, the suction catheter may not
remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac
dysrhythmias could result.

11.
The nurse is caring for a client with a chest tube in the right thorax. On first assessment
the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled
to undergo a chest x-ray examination, and the transporters have arrived to take him by
wheelchair to the radiology department. The nurse considers whether the chest tube
should be clamped or not during the trip to the radiology department. The nurse makes the
which correct decision?
A) Clamp the chest tube, but vent the system to air.
B) Clamp the chest tube and disconnect it from the wall suction.
C) Do not clamp the chest tube and disconnect it from the wall suction.
D) Do not clamp the chest tube and connect it to temporary intermittent suction.

Feedback: INCORRECT
A bubbling chest tube (in the water-seal portion) should never be clamped because it
provides the only exit for air accumulating in the pleural space. If the tube is clamped,
tension pneumothorax could occur, which could be fatal. There is no advantage to
clamping the chest tube but venting the system. Clamping of the chest tube prevents
communication of the chest tube with the venting system or with the wall suction. There is
no such thing as "temporary suction" for a chest tube system.

12.
A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the
nurse performs is to be sure that:
A) The oxygen flow meter is set at 2 L/min.
B) The mask is connected to a heating element.
C) The bag attached to the mask is inflated at all times.
D) The straps securing the mask are not causing skin ulcers over the top of the ears.

Feedback: INCORRECT
If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing
in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all
times. Checking the straps to make sure they are not causing skin ulcers is important but
not crucial. For a nonrebreathing mask 2 L/min is far too low a flow setting. The oxygen
flow should be set at 10 L/min or more. Otherwise, the bag will collapse. Heating the fluid
used to increase humidity is not essential.

13.
A client with known chronic obstructive pulmonary disease (COPD) is admitted to the
emergency department with multiple minor injuries following an automobile accident. To
ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what
rate and for what reason?
A) 6 L/min to provide sufficient oxygen to the myocardium following trauma
B) 3 L/min to stimulate the respiratory chemoreceptors, which will result in increased
respiratory rate
C) 10 L/min to suppress the respiratory drive, which is necessary for adequate artificial
ventilation
D) 2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress
the hypoxic drive

Feedback: INCORRECT
Clients without COPD rely on low PaO2 as a stimulus to breathe. Thus, increasing the PaO2
would stop the client from breathing. Low oxygen therapy is recommended for clients with
COPD who are severely hypoxic. Options 1 and 2 give the client too much oxygen and
might suppress the client's breathing. Because the client experienced only minor injuries,
the client presumably is still breathing on his or her own; therefore, option 3 is incorrect
because artificial ventilation is not necessary.

14.
The nurse is caring for a client who has undergone cardiac catheterization. The client says
to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac
output?" Which of the following is the nurse's best response?
A) "It is best to ask your doctor."
B) "Did the test make you feel upset?"
C) "The normal cardiac output for an adult is 4 to 6 L/min."
D) "Are you able to explain why are you asking this question?"

Feedback: INCORRECT
The client asked a direct question that the nurse should be able to answer. Normal cardiac
output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be
referred to physicians. There is no harm in answering this question. When using
therapeutic communication, the nurse should never ask a client to justify his or her
feelings by inquiring why a question was asked. There is no evidence that this client is
upset

15.
A client asks why smoking is a major risk factor for heart disease. In formulating a
response, the nurse incorporates the understanding that nicotine:
A) Causes vasodilation
B) Causes vasoconstriction
C) Increases the level of high-density lipoproteins
D) Increases the oxygen-carrying capacity of hemoglobin

Feedback: INCORRECT
Nicotine causes vasoconstriction, which restricts blood flow to the heart and peripheral
tissues and increases the risk of hypertension and subsequently heart disease as a
complicating factor. Nicotine does not cause vasodilation. Nicotine decreases the oxygen-
carrying capacity of hemoglobin. Nicotine decreases the level of high-density lipoproteins
and elevates the level of harmful low-density lipoproteins, which leads to atherosclerosis.

16.
Symptoms associated with anemia include which of the following? (Select all that apply.)
A) Increased breathlessness
B) Decreased breathlessness
C) Increased activity tolerance
D) Decreased activity tolerance

Feedback: INCORRECT
Clients with anemia have fatigue, decreased activity tolerance, and increased
breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an
increased heart rate.
Correct Answer(s): A, D

17.
Which of the following assessment data indicate that the client's airway needs suctioning?
(Select all that apply.)
A) Drooling
B) Production of thin, watery sputum
C) Decreased coughing ability
D) Secretions that clear with coughing
E) Abnormal lung sounds only in left lower lobe

Feedback: INCORRECT
Suctioning is necessary when the client is unable to clear respiratory secretions from the
airways. Signs that a client's airway needs suctioning include a change in respiratory rate
or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions
or vomitus in the mouth, and coughing without clearance of secretions from the airway.
Correct Answer(s): A, C, E

18.
The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes
which of the following symptoms? (Select all that apply.)
A) Distended neck veins
B) Bilateral crackles in the lungs
C) Weight gain of 2 lb in past 2 days
D) Shortness of breath, especially at night

Feedback: INCORRECT
Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This
causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are
usually related to the lungs.
Correct Answer(s): B, D

19.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and
anxiety. The nurse helps the client to breathe better by doing which of the following?
A) Implementing guided imagery
B) Instructing the client to perform pursed-lip breathing
C) Elevating the head of the bed to semi-Fowler's or Fowler's position
D) Encouraging the client to drink a full glass of water to liquify secretions

Feedback: INCORRECT
Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's
position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus
increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and
maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide
exchange. Too high an elevation of the head of the bed could force the diaphragm into the
thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the
future, but right now the client needs more acute care. Guided imagery may help in the
future, but now is not the time to implement this intervention.
Correct Answer(s): B, C

Pasted from <http://evolvels.elsevier.com/Section/Assessment/Question/GradeDelivery.aspx?
entry_id=BBD6B737A8CB411489CD7580AFAD498E&response_id=1CFA3F2B88534141969457AB89460EAE>

Nutrition (chap. 44)
Nursing process and nutrition

Assessment
Clients who are malnourished on admission are at greater risk of life threatening complications
during hospitalization such as arrythmias, sepsis, or hemorrhage
 Identify the signs and symptoms associated with altered nutrition
 Gather data from clients regarding nutritional practices
 Determine clients nutritional energy needs
o REE x activity or illness factor
 Obtain clients dietary history

Use:
 Screenings
 Objective measures (height, weight, weight change, primary dx.)
 Combine with multiple objective measures
 Subjective global assessment - uses client hx, weight and
physical assessment data to evaluate nutritional status
 Mini nutritional assessment- older adults, has 18 items that are
divided into screening and then assessment
 Anthropometry
 Measurement system of size and makeup of the body.
 Height and weight are taken at the same time each day with same scale,
clothing, etc.
 Compare height and weight with the standards for Height weight relationship
IBW
 Lab and biochemical tests
 Measures of plasma proteins such as albumin, transferring, prealbumin, retinol
binding protein, total iron binding capacity, and hemoglobin
 Dietary hx and health hx
 Physical examination
 See table pg. 1102
 Dysphagia
 Difficulty when swallowing
 Causes can include
 Myogenic
 Myasthenia gravis aging
 Muscular dystrophy Plymyositis
 Neurogenic
 Stroke cerebral palsy
 Guillain barre syndrome multiple sclerosis
 Lou gehrig disease parkinsons disease
 Obstructive
 Benign peptic stricture lower esophageal ring
 Candidiasis head and neck cancer
 Inflammatory masses trauma/surgical resection
 Anterior mediastinal masses cervical sponhylosis
 Other
 Gastrointestinal or esophageal resection
 Rheumatologic disorders
 Connective tissue disorders
 Vagotomy

Nursing diagnosis
 Dx are related to either the actual nutrional problems or problems that place the client at risk
for nutritional deficiencies such as oral trauma, severe burns, or infections
o Risk for aspiration
o Constipation
o Diarrhea
o Deficient knowledge

Planning
 Select nursing interventions to promote optimal nutrition
 Select nursing interventions consistent with therapeutic diets
 Consult with other health care prof. to adopt interventions that reflect the clients needs
 Involve family when designing interventions

Implementation
 Health promotion
o Incorporating knowledge of nutrition into lifestyle serves as prevention against
developing diseases.
 Acute care
o Advancing diets - clients with decreased immune function require special diets that
decease their exposure to microorganisms and are higher in selected nutrients
o Promoting appetite- provide an environment that promotes nutritional intake
o Assisting clients with oral feeding
o Enteral tube feeding
 Nutrients given in the GI tract, less metabolic problems
 Have four different types of formulas.
 Feeding this route reduces sepsis, minimizes the hypermetabolic response to
trauma, and maintains intestinal structure and function
 A serious complication is aspiration of formula into tracheobronchial tree
 The formula irritates the bronchial mucosa, decreasing the blood supply
to affected pulmonary tissue, this lead to necrotizing infection (b/c high glucose),
pneumonia, potential abscess formation.
 ADVANTAGES
 Promotes some satiety
 Protects GI tract
 IgA secretion
 < atrophy of GI/Pancreas
 < Infection (bacterial translocation)
 < gallbladder sludge/stones
 Less sepsis/GI problems
 Better vitamin absorption
 Vit K production
 B vitamins
 Less expensive/ home use
 Disadvantages
 Need GI access with tube
 Tube problems
 Patient comfort
 Risk for aspiration
 Metabolic problems
o Enteral access tubes
 Nose - nasogastric, Nasoduodenal, Nasojejunal
 4 weeks or less
 Large bore >12 french
 Small bore 8-12 french
 Surgically - gastrostomy, jejunostomy
 Endoscopically- percutaneous endoscopic gastrostomy (PEG), or (PEJ)
 Surgically or endoscopically for more than 4 weeks
Check Residual:
o If tube is in stomach! Because it holds fluid
o Pt. should be put on right side 20 min before checking
o Check approx. every 4-6 hours, especially with continuous feedings
o Always use 50-60 mL syringe
o Flush line with air/water first
o If more than 60mL dump in cup and pull out again
o Secretions alone = 140 - 190 ml/hr
o If secretions less or equal to 200mL then reinstill all of it
 If over then put 200 ml back and count as output
o If residual is high then recheck in 1 hour
o Parenteral nutrition
 Nutrients are provided IV
 Clients that are unable to absorb or digest from enteral
 Short term needs receive solutions less than 10% dextrose via peripheral vein
(arm)
 Needs greater than 10 % solution requires central venous catheter/ PICC
 Goes into superior vena cava
 Make sure it is sutured in!
 Complications of PN
 Infection
 Fungus
 Gram positive, gram negative bacteria
 Metabolic problems
 Hyperglycemia, hypoglycemia, hyperosmolar
 Prerenal azotemia
 Essential fatty acid deficiency
 Electrolyte and vit excesses and deficiencies
 Hyperlipidemia
 Mechanical problems
 Insertion
 Air embolus
 Pneumothorax, hemothorax,
 Dislodgement
 Thrombosis of great vein
 phlebitis

Evaluation
 Reassess signs and symptoms associated with altered nutrition
 Determine clients satisfaction with nutritional therapy
EVOLVE QUESTIONS (NUTRITION)

 1.
 The nurse is teaching a client about healthy nutrition. The nurse recognizes that the
client understands the teaching when the client makes which of the following
statements?
 A) "I need to stop eating red meat."
 B) "I will increase the servings of fruit juice to four a day."
 C) "I will make sure that I eat a balanced diet and exercise regularly."
 D) "I will not eat so many dark green vegetables and eat more yellow vegetables."

 Feedback: INCORRECT
 The client should adopt a balanced eating pattern that includes a variety of nutrient-
dense foods and beverages among the basic food groups. The nurse should
encourage the client to consume fruits, vegetables, whole-grain products, and fat-
free or low-fat milk while staying within energy needs. Total fat intake should be
kept between 20% and 35% of total calories with most fats coming from
polyunsaturated or monounsaturated fatty acids. The client should choose and
prepare foods and beverages with little added sugars or sweeteners and foods with
little salt while at the same time eating potassium-rich foods.
 2.
 The nurse teaches a client who has had surgery to increase intake of which nutrient
to help with tissue repair?
 A) Fat
 B) Protein
 C) Vitamins
 D) Carbohydrate

 Proteins provide a source of energy and are essential for synthesis (building) of body
tissue in growth, maintenance, and repair. Proteins are also required for blood
clotting, fluid regulation, and acid-base balance. Fats are important for metabolic
processes. Vitamins are chemicals used as catalysts in biochemical reactions. They
are essential to normal metabolism and are present in small amounts in foods.
Carbohydrates are used for energy.

 3.
 Which action should the nurse take initially to verify correct positioning of a newly
placed small-bore feeding tube?
 A) Place an order for a radiograph to check position.
 B) Confirm the distal mark on the feeding tube after taping.
 C) Test the pH of the gastric contents and observe the color.
 D) Auscultate over the gastric area as air is injected into the tube.

 Radiography will confirm placement more reliably than other methods of checking
placement.


 4.
 Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the
presence of which bacteria when reviewing the laboratory data for a client suspected
of having PUD?
 A) Micrococcus
 B) Staphylococcus
 C) Corynebacteria
 D) Helicobacter pylori

 H. pylori is a bacterium that causes peptic ulcers, and its presence can be confirmed
by laboratory tests. It is treated with antibiotics that control the bacterial infection.
The other bacteria listed are not associated with PUD.

 5.
 The nurse is assessing a client receiving enteral feedings via a small-bore
nasointestinal tube. Which assessment finding needs further intervention?
 A) Gastric pH of 3.0 during placement check
 B) Weight gain of 1 lb over the course of a week
 C) Active bowel sounds in the four abdominal quadrants
 D) Gastric residual aspirate of 300 mL for the second consecutive time

 Gastric residual aspirate of 300 mL indicates that the client is not digesting the food.
Active bowel sounds in all four quadrants is a positive sign. Weight gain of 1 lb in a
week is an appropriate weight variance. A gastric pH of 3.0 is expected.
 6.
 The nurse evaluates laboratory findings for a client hospitalized because of chronic
obstructive pulmonary disease. Which finding is consistent with poor nutrition?
 A) Nitrogen balance of 3 g
 B) Transferrin level of 370 mg/dl
 C) Hemoglobin level of 13.8 g/dl
 D) Serum albumin level of 2.5 g/dl

 Factors that affect serum albumin levels include hydration; hemorrhage; renal or
hepatic disease; large amounts of drainage from wounds, drains, burns, or the
gastrointestinal tract; steroid administration; exogenous albumin infusions; age; and
trauma, burns, stress, or surgery. A normal serum albumin level is 4.0 g/dl. The
other options are incorrect.

 7.
 The home health nurse is seeing the following clients. Which client is at greatest risk
for experiencing inadequate nutrition?
 A) A 55-year-old obese man recently diagnosed with diabetes mellitus
 B) A recently widowed 76-year-old woman recovering from a mild stroke
 C) A 22-year-old mother with a 3-year-old toddler who underwent tonsillectomy
 D) A 46-year-old man recovering at home following coronary artery bypass surgery

 The 76-year-old woman has multiple issues confronting her that put her at a higher
risk for inadequate nutrition, including the recent death of her spouse and her recent
stroke. The other clients do have some risk of inadequate nutrition, but not as great
a risk as the older widow.

 8.
 The nurse is measuring the pH of fluid from a jejunostomy tube and suspects that
the tube has migrated into the stomach when the pH reading is:
 A) 3.0
 B) 4.0
 C) 5.0
 D) 6.0

 The pH of gastric contents is low and acidic (3 or less), whereas the pH of the small
intestine is higher because of the bicarbonate released.

 9.
 The nurse wants to begin feeding a client through a small-bore feeding tube that was
recently placed. Before initiating feedings through this tube, the nurse confirms tube
placement by:
 A) Aspirating fluid contents from the stomach
 B) Requesting confirmation of placement via radiographic examination
 C) Measuring the pH of the fluid aspirated through the small-bore tube
 D) Injecting air through the feeding tube while auscultating for air in the stomach

 The most reliable method for verifying the placement of a small-bore feeling tube is
radiographic examination. None of the other methods is as reliable.
 10.
 The nurse is caring for a client experiencing dysphagia. Which interventions will help
decrease the risk of aspiration during feeding? (Select all that apply.)
 A) Have the client sit upright in a chair.
 B) Give liquids at the end of the meal.
 C) Place food in the strong side of the mouth.
 D) Provide thin foods to make it easier to swallow.
 E) Feed the client slowly, allowing time for the client to chew and swallow.
 F) Encourage the client to lie down to rest for 30 minutes after eating.

 The nurse should have the client sit upright or in high-Fowler's position and then
feed the client slowly, allowing the client time to chew and swallow. Thin foods
should be thickened to the consistency of mashed potatoes to make swallowing
easier, and the food should be placed in the strong side of the mouth. Liquids should
be thickened, but the client should be allowed to have them as desired. The client
should sit upright for 30 minutes after eating to ensure digestion and prevent reflux
of the food.
Correct Answer(s): A, C, E

 11.
 Which of the following statements about water-soluble vitamins is true? (Select all
that apply.)
 A) They cannot be stored.
 B) They often cause toxicity.
 C) They must be consumed daily.
 D) Supplements must be taken to reach the recommended daily allowance of these
vitamins.

 Water-soluble vitamins are eliminated daily; they are not stored. Thus they must be
consumed daily. Although toxicity may occur with megavitamin intake, the possibility
of toxicity is low. A healthy diet should provide the necessary amount of water-
soluble vitamins without the need for supplementation.
Correct Answer(s): A, C

 12.
 When evaluating the history of a client who has gastrointestinal (GI) upset, the
nurse is sure to assess the client for routine ingestion of which of the following?
 A) Beer
 B) Aspirin
 C) Acetaminophen
 D) High-fiber foods

 Alcohol and aspirin are two substances directly absorbed through the lining of the
stomach. This can contribute to GI upset. High-fiber foods should reduce GI
symptoms because they stimulate peristalsis. Acetaminophen does not commonly
cause GI symptoms. It is more likely to cause problems with the liver.
Correct Answer(s): A, B
 13.
 A woman is considering becoming pregnant. The nurse practitioner recommends that
the client begin to consume which of the following before attempting pregnancy to
prevent neural tube defects in the fetus?
 A) Calcium
 B) Folic acid
 C) Vitamin C
 D) Riboflavin

 The importance of consuming folic acid to prevent neural tube deficits has been
proven. The other vitamins and minerals are important but not essential.

 14.
 A client has gained 2 lb of weight in the past day. The nurse calculates this weight
gain to be __________ ml of fluid.

Correct Answer(s): 1000



 Pasted from <http://evolvels.elsevier.com/Section/Assessment/Question/GradeDelivery.aspx?
entry_id=E77F659E8E324BAF9228A81C1D8D6E7D&response_id=D2D222C19CB04DC4BFB84667A8824B60>
PREOPERATIVE (MODULE 16)

Classification of surgery:
 Seriousness
o Major - extensive reconstruction or alteration in body parts; poses great risk to well
being. (coronary artery bypass, colon resection…)
o Minor - minimal alteration in body parts; designed to correct deformities, minimal risk
compared with major (cataract extraction, facial plastic surgery…)
 Urgency
o Elective
o Urgent - necessary for clients health, often prevents additional problems from
developing (excision of cancerous tumor, removal of gallbladder for stones…)
o Emergency- must be done immediately to save life or preserve function of body part
(perforated appendix, repair of traumatic amputation…)
 Purpose
o Diagnostic
o Ablative - excision or removal of diseased body part (amputation…)
o Palliative - relieves or reduces intensity of disease symptoms; will not produce cure
(colostomy..)
o Reconstructive/restorative- restores function or appearance to traumatized or
malfunctioning tissues (internal fixation of fractures, scar revision)
o Procurement for transplant- removal of organs/tissue from person pronounced brain
dead for transplantation into other person.
o Constructive
o Cosmetic

PREOPERATIVE
The nursing process in preoperative surgical phase
ASSESSMENT
 The aim of the assessment is to establish clients normal preoperative function and to prevent
postoperative complications

Assess:
 Physical examination focused on the clients hx and planned surgery
 Assessment of factors that pose surgical risks for client
 Clients previous experience with surgery
 Clients coping resources
 Results of preoperative diagnostic tests

 Risk factors:
o Age - very young or very old - immune system are immature and then declining
o Nutrition - with surgery they have increased energy requirements so in wound healing it
makes nutrition very important.
o Obesity - reduces ventilatory and cardiac function.
 Embolus, stelectasis and pneumonia are the more frequent postop
complications
o Obstructive sleep apnea - partial or complete obstruction of airway during sleep
o Immunocompromised -
o Pregnancy
o Fluid and electrolyte imbalance-
 As result from adrenocortical stress response the body retains sodium and
water and loses potassium within the first 2-5 days after surgery
 Main - Na, K, Cl
 If depletion of K can have heart arrhythmias…
o Poor physical condition

 Medication hx- certain medications have special implications for the surgical client, creating
greater risks for complications.
 Antibiotics
 Antidysrhythmics
 Anticoagulants
 Anticonvulsants
 Antihypertensives
 Corticosteroids
 Insulin
 Diuretics
 Nsaids
 Herbal therapies
 Smoking - those that smoke have increased secretions that can block airway
 Allergies-
 Alcohol and substance use and abuse -
o Delirium tremens - abrupt cessation of alcohol, will see agitation, tremors, hallucination
that can last 3-6 days followed by deep sleep
o Alcohol causes malnutrition
o Substance abuse - usually have difficult peripheral veins so need central line
 Support services - check that there are family or friends to provide support
 Occupation - assess clients occupation hx to anticipate possible side effects of surgery on
recovery
 Preoperative pain assessment
 Psychosocial assessment
 Culture
 Client expectations
 Physical examination
 Laboratory and diagnostic testing
o Hgb - 13.1 - 17.2 g/dl (males) 11.7 - 16 g/dl (females)
o Hct - 35%- 47%
o K+ - 3.5 - 5.0 mEq/L
o Na - 136-146 mEq/L
o Cl - 98-107 mEq/L
o BUN - 8-23 mg/dl
o Creatinine - 0.6 - 1.2 mg/dl
o Glucose - 60-100 mg/dl

DIAGNOSIS
 Client with preexisting health problems is likely to have variety of risk diagnosis

PLANNING
 Involve the client and family in preop instruction
 Provide therapies aimed at minimizing the clients fear or anxiety regarding surgery
 Plan therapies to reduce surgical risks
 Consult with other health care professionals

IMPLEMENTATION
 Informed consent- outlines need for surgery, steps, risks, expected results and alternatives
o Physicians role is to inform pt. Nurses role is to witness surgeons explanation and pt
signature, and testifies to pts understanding of benefits/risks
o Preoperative teaching -
 Deep breathing and coughing
 Insentive spirometry
 Turning
 Leg exercises, ambulation
 Pain meds
 What to expect - Ivs, dressings, tubes, oxygenation
 Physical preparation
o Maintenance of normal fluid electrolyte balance - NPO
o Reduction of risk for surgical wound infection
o Prevention of bowel and bladder incontinence
o Promotion of rest and comfort
 Preparation on day of surgery
o Hygiene vital signs
o Hair and cosmetics documentation
o Removal of prostheses performing special procedures
o Safeguarding valuables administering preop meds
o Preparing the bowel and bladder latex sensitivity/allergy
o Eliminating wrong site and wrong procedure

EVALUATION
 Evaluate clients knowledge of surgical procedure and planned postoperative care
 Have the client demonstrate postoperative exercises
 Observe behaviors or nonverbal expressions of anxiety or fear
 Ask if the clients expectations are being met

Intraoperative surgical phase
Nursing process in intraoperative surgical phase:
ASSESSMENT
 In presurgical care unit conduct focused preoperative assessment to verify client is ready for
surgery and to plan intraoperative care.
 Verify with the client the planned surgical procedure and the surgical site before anesthesia is
administered
DIAGNOSIS
 Review preop dx, and modify them to individualize care plan in the operating room
PLANNING
 Ex; maintain skin integrity
IMPLEMENTATION
 Acute care
o Physical preparation - apply monitoring devices, antiembolism stockings
o Monitor IV fluid infusions, monitor urinary nasogastric output, maintain surgical asepsis,
monitor for cardiac and respiratory arrest, allergic reactions
o Introduction of anesthesia
 General - immobile, quiet client who does not recall the surgical procedure.
IV/inhalation agents produce unconsciousness;
 Regional - loss of sensation to the are of body, no loss of consciousness, but may
be sedated
 Local - loss of sensation at specific site, injection locally or applied topically
 Conscious sedation - decreased LOC
 Side effects of anesthetic agents
 CV depression or irritability
 Respiratory depression
 Liver and kidney damage
EVALUATION
 Evaluate intervention implemented during intraoperative phase throughout surgical procedure

Postoperative surgical phase
 Clients who undergo general anesthesia are more likely to face comlications than those who
have only local
 Client who has undergone regional or general anesthesia usually transfers to PACU to be
stabilized before discharge, whereas client who has had local goes directly to the nursing unit or
back to ambulatory surgery center.
 Immediate postop recovery
o Surgery tem reports to PACU nurse
 Anesthesia used Ivs, blood administered
 Complications during surgery - excess blood loss, cardiac dysrhythmias
o Monitor VS, ECG, pulse oximetry
o PROTECT THE AIRWAY
o Maintain BP
o Monitor return of consciousness, sensation and motion
o Assess for normothermia
o Assess perfusion, surgical site,
 Surgical site note drainage
o Promote fluid electrolyte balance
o Manage drainage systems
 Check what is coming out
o Promote comfort
o Transfer from PACU when stable
 Discharge from postanesthesia
o Based on vital sign stability in comparison with preoperative data
o Postanesthesia recovery score (PARS) - pt must have 8-10 score before being released
o Handoff communication occurs between PACU nurse and nurse on nursing unit.
 Recovery in ambulatory surgery
o Initiate post op teaching with clients and family members
o Monitor clients but not at the same intensity as phase I (PACU)
 Postoperative convalescence
o Focus is on returning client to relatively functional level of wellness as soon as possible

Nursing process postoperative care
ASSESSMENT
 Upon arrival to recovery, measure viral signs and key observations at least every 15 min
depending on clients condition and unit policy
 Airway and respiration
o Assess patency, respiratory rate, rhythm, depth of ventilation, symmetry of chest wall
movements, breath sounds, color of mucous membranes
o Pulse ox at least 92%
o Maintain adequate postioning
o Great concern is airway obstruction
 Circulation
o Assess perfusion by capillary refill, , pulses, skin color
o Assess HR, rhythm, BP
o Peripheral pulse checks distal to surgical site
o Check for bleeding
o Prevent DVT
 Temperature control
 Fluid and electrolyte balance
o Check IV fluid rate
o Electolytes
o Daily weight -accurate assessment of fluid status
 Neurological functions
o Oriented to person, place, time, follows commands
o Check pupil reflexes, hand grips, movement of extremities
o Check sensation along dermatomes - touch client bilaterally in same dermatome and
document if the client feels touch
 Skin integrity and condition of the wound -
o note rashes, petechiae, abrasions, or burns
o Observe amount and color, odor, and consistency of drainage on dressings
o Many surgeons change the first dressing themselves
 Genitourinary function
o Bladder distention
o Foley
o Expect void 6-8 hr after sx/catheter removal
 Note color of urine, freely draining from catheter
 Gastrointestinal function
o Anesthesia slows GI motility and often causes nausea
o Assess bowel sounds
o Look for abdominal distention
o Avoid sudden movement
o Maintain NG tube patency/suction; monitor output
o Dietary progression- ice chips, clear liquids then solids.
 Comfort
o Pain meds
o IV, PCA, IM, PO
o Avoid pain peaks and troughs
o Nonpharmacological measures
o Work with pt/family/physician to get pain under control
 Client expectations
o Assess pt and family expectations for recovery

Postoperative complications:
 Respiratory -
 Atelectasis - collapse of alveoli with retained mucous secretions. S/S include
elevated resp. rate, dyspnea, fever, crackles
 Pneumonia- inflammation of alveoli (s/s include fever, chills, productive cough,
chest pain, purulent mucus)
 Hypoxemia - inadequate concentration of oxygen in arterial blood (s/s
restlessness, confusion, dyspnea, high or low BP
 Pulmonary embolism - emolus blocking pulmonary arterial blood flow to one or
more lobes of lung (s/s sudden chest pain, dyspnea, cyanosis,, drop in BP)
 Circulatory -
 Hemorrhage- (s/s hypotension, weak and rapid pulse, cool and clammy skin,
rapid breathing, restlessness and < urine output
 Hypovolemic shock (s/s same as hemorrhage)
 Thrombophlebitis- inflammation of vein (s/s inflammation of involved site,
aching or cramping pain, vein feels hard)
 Thrombus (s/s localized tenderness along distribution of venous system)
 Embolus
 Gastrointestinal-
 Paralytic ileus - nonmechanical obstruction of bowel (
 Abdominal distention- retention of air within intestines and abdominal cavity
(s/s increased abdominal girth, tympanic percussion over ab quadrants
 Nausea and vomiting
 Genitourinary -
 Urinary retention (s/s inability to void, restlessness, bladder distention) appears
6-8h after surgery
 UTI (s/s dysuria, itching, abdominal pain, possible fever, cloudy urine, wbc and
leukocyte esterase positive
 Integumentary
 Wound infection (s/s warm, red , tender skin around incision)
 Wound dehiscence- separation of wound edges at suture line (s/s increased
drainage and appearance of underlying tissue)
 Wound evisceration - protrusion of internal organs and tissues through incision
 Skin breakdown
 Nervous-
 Intractable pain- pain that is not amenable to analgestics and pain alleviating
interventions

DIAGNOSIS
 cluster new post op assessment data and identify relevant new diagnoses.
 Fear, pain, risk for infection, knowledge deficit...
PLANNING
 Goals and outcomes - consider effects of stress of surgery and limitations it produces when
establishing goals, expected outcomes and interventions.
 Set priorities - as client progresses, focus priorities on advancement of client activity to return
client to preop functioning
 Collaborative care

IMPLEMENTATION
EVALUATION

EVOLVE QUESTIONS
1.
An obese client is at risk for poor wound healing postoperatively because:
A) Risk for bleeding is increased
B) Ventilatory capacity is reduced
C) Fatty tissue has a poor blood supply
D) Resumption of normal physical activity is delayed

Feedback: INCORRECT
The obese client is susceptible to poor wound healing and wound infection because of the
structure of fatty tissue, which contains a poor blood supply. This slows delivery of the
essential nutrients, antibodies, and enzymes needed for wound healing. Ventilatory
capacity could affect postoperative healing but is not decreased by obesity. Risk for
bleeding would not affect wound healing. If there were poor wound healing, the resumption
of normal activity could be delayed, but this delay would be caused by the poor wound
healing, not vice versa.

2.
The nurse asks each client preoperatively for the name and dose of all prescription and
over-the-counter medications taken before surgery because these medications:
A) May cause allergies to develop.
B) Are automatically ordered postoperatively.
C) May increase the risks for anesthetic and surgical complications.
D) Should always be taken the morning of surgery with sips of water.

Feedback: INCORRECT
All medications must be reviewed to ensure that they will not increase the risks associated
with anesthesia and surgery. Medications will not cause allergies to develop during or after
surgery. Not all medications are automatically ordered postoperatively. Medications are
taken as prescribed, or held as necessary, at the appropriate time, not just in the morning.

3.
A client who smokes two packs of cigarettes per day is most at risk postoperatively for:
A) Atelectasis, fever, and pneumonia
B) Hypotension, confusion, and elevated glucose level
C) Hypotension, cardiac dysrhythmias, and fever
D) Urinary infection, fever, and malignant hyperthermia

Feedback: INCORRECT
After surgery clients who smoke have greater difficulty than nonsmokers in clearing the
airways of mucous secretions, and the importance of postoperative deep breathing and
coughing should be emphasized to such clients. Urinary infection, hypotension, confusion,
and elevated glucose levels are not necessarily associated with smoking.

4.
Family members should be included when the nurse teaches the client preoperative
exercises so they can:
A) Coach the client postoperatively.
B) Demonstrate the exercises to the client at home.
C) Relieve the nurse by getting the client to do the exercises every 2 hours.
D) Practice the exercises with the client while the client waits to be taken to the operating
room.

Feedback: INCORRECT
Often a family member serves as the client's coach when the client performs postoperative
exercises after returning from surgery. The coach may also help at home, but the client
should be able to do his or her exercises correctly before surgery and should not need
demonstration. Practicing exercises while waiting to be taken to the operating room may
not be practical. The nurse is always responsible for ensuring that the exercises are
initiated as ordered.

5.
Maintaining normal glucose levels during the postoperative period reduces which
complication?
A) Ileus
B) Bleeding
C) Wound infection
D) Deep vein thrombosis

Feedback: INCORRECT
Evidence indicates that maintaining normal glucose levels during the postoperative period
reduces the incidence of infections. Glucose levels are not associated with ileus, bleeding,
or deep vein thrombosis.
6.
In the postanesthesia care unit the nurse notes that the client is having difficulty breathing
because of an obstruction. The nurse would first:
A) Suction the pharynx and bronchial tree.
B) Give oxygen through a mask at 10 L/min.
C) Ask the client to use an incentive spirometer.
D) Position the client so that the tongue falls forward.

Feedback: INCORRECT
In clients recovering from anesthesia the tongue causes the majority of airway
obstructions. Clients should remain lying on their sides until they are able to maintain their
own airways. Suctioning before removing a structural obstruction will not be helpful.
Supplemental oxygen may be helpful after the obstruction is removed. Clients in this state
will not be able to use the incentive spirometer.
7.
Because an older adult is at increased risk for respiratory complications after surgery, the
nurse should:
A) Withhold pain medications and ambulate the client every 2 hours.
B) Monitor fluid and electrolyte status every shift and measure vital signs including
temperature every 4 hours.
C) Orient the client to the surrounding environment frequently and ambulate the client
every 2 hours.
D) Encourage the client to turn, deep breathe, and cough frequently, and ensure adequate
pain control.

Feedback: INCORRECT
The nurse should encourage the client to perform coughing exercises every 2 hours while
awake and should maintain pain control to promote deep, productive coughing. Pain
medications should never be withheld from a client. Checking vital signs every 4 hours is
appropriate.

8.
A client with a longer than normal prothrombin time (PT) or activated partial
thromboplastin time (APTT) is at risk postoperatively for:
A) Bleeding
B) Infection
C) Low urine output
D) Cardiac dysrhythmias

Feedback: INCORRECT
Both PT and APTT are measures of clotting ability. A client with a prolonged PT or APTT is
at risk of bleeding. These tests do not measure urine output, infection, or cardiac rhythm.

9.
When a nonbariatric client is deep breathing and coughing the client should be sitting
because this position:
A) Is more comfortable
B) Facilitates expansion of the thorax
C) Helps the client to splint with a pillow
D) Increases the client's view of the room and is more relaxing

Feedback: INCORRECT
The thorax can expand better when the client is upright. This position may or may not be
more comfortable for the client. The changed view of the room may or may not be of
interest to the client. It is easier for the client to splint when upright, but the primary
purpose for having the client sit upright is to facilitate expansion of the thorax.
10.
The nurse notes that a postsurgical client has a heart rate of 130 beats per minute and a
respiratory rate of 32 breaths per minute. The nurse also assesses jaw muscle rigidity and
rigidity of the limbs, abdomen, and chest. What does the nurse suspect and what
intervention is indicated?
A) The nurse suspects infection and should notify the surgeon and anticipate
administration of antibiotics.
B) The nurse suspects pneumonia and should listen to breath sounds, notify the surgeon,
and anticipate an order for chest radiography.
C) The nurse suspects hypertension and should check blood pressure, notify the surgeon,
and anticipate administration of antihypertensives.
D) The nurse suspects malignant hyperthermia and should notify the
surgeon/anesthesiologist immediately, prepare to administer dantrolene sodium, and
monitor vital signs frequently.

Feedback: INCORRECT
Malignant hyperthermia is a potentially lethal condition that can occur in clients receiving
general anesthesia. It should be suspected when there is unexpected tachycardia and
tachypnea; elevated carbon dioxide levels; jaw muscle rigidity and rigidity of the limbs,
abdomen, and chest; and hyperkalemia. The nurse will immediately administer dantrolene
sodium ordered by the health care providers. The other options are incorrect.
11.
Through experience and knowledge, the nurse knows that the client will commonly
experience the most severe postoperative pain at what time?
A) The third postoperative day
B) The fourth postoperative day
C) Immediately after the surgery
D) The first 12 to 36 hours after surgery

Feedback: INCORRECT
Postoperative pain generally decreases after the second or third day. Immediately
following surgery the anesthetic is still effective. Commonly the most severe pain is
experienced 12 to 36 hours after surgery. The nurse must keep in mind that all clients
should be treated individually.

12.
Surgical procedures are classified in terms of seriousness, urgency, and purpose. The
designation of a procedure as an "emergency surgical procedure" relates to which of the
following categories?
A) Purpose
B) Urgency
C) Diagnostic
D) Seriousness

Feedback: INCORRECT
"Emergency surgery" as well as "elective surgery" and "urgent surgery" are designations
based on urgency. The urgency classification describes a time factor. The seriousness of a
surgical procedure is designated by the terms major and minor, which indicate extensive
and minimal alteration of body parts, respectively. Diagnostic is one of seven descriptors
indicating the purpose of a surgical procedure. The others are ablative, palliative,
reconstructive/restorative, procurement for transplant, constructive, and cosmetic.
13.
The American Society of Anesthesiologists has assigned surgical classifications to clients
based on what characteristic?
A) Physical status of the client
B) Type of anesthesia used
C) Purpose and seriousness of the procedure
D) Seriousness and urgency of the procedure

Feedback: INCORRECT
The American Society of Anesthesiologists has assigned classifications to clients based on
the client's physiological condition independent of the proposed surgical procedure.
Difficulties during surgery occur more frequently for clients whose assigned classifications
reflect poor physical status. Clients in classes I and II and stable clients in class III are
considered acceptable candidates for ambulatory or outpatient surgery. The surgical
procedure itself is classified according to seriousness, urgency, and purpose.
14.
On admission to the ambulatory surgical unit the client tells the nurse, "I take naproxen for
arthritic pain." Why should the nurse inform the surgeon of this?
A) Nonsteroidal antiinflammatory drugs (NSAIDs) do not interfere in any way.
B) NSAIDs may cause mild respiratory depression.
C) NSAIDs inhibit platelet aggregation and may prolong bleeding time.
D) NSAIDs impair cardiac conduction during anesthesia.

Feedback: INCORRECT
NSAIDs increase the client's susceptibility to postoperative bleeding by inhibiting platelet
aggregation and prolonging bleeding time. Antidysrhythmics, not NSAIDs, impair cardiac
conduction during anesthesia. Antibiotics may cause mild respiratory depression by
depressing neuromuscular transmission, but NSAIDs do not.

15.
While assessing a client after surgery, the nurse notes dull breath sounds and dyspnea.
What are the most appropriate nursing interventions?
A) Continue observations.
B) Promote adequate fluid intake but avoid the use of straws.
C) Apply antiembolism stockings and turn the client every 1½ hours.
D) Encourage deep breathing and coughing exercises and increase mobility.

Feedback: INCORRECT
Dull breath sounds and dyspnea may suggest atelectasis. Therefore it is important for the
client to do deep breathing and coughing exercises and to increase mobility and activity.
Turning the client is beneficial. Sudden chest pain is associated with pulmonary embolism.
Antiembolism stockings are used as a preventative measure for emboli. Gastrointestinal
complications can be lessened or prevented by adequate fluid intake and avoidance of the
use of straws.
16.
Nursing has made significant contributions in what areas promoting positive client
outcomes after surgery?
A) Discovery of effective anesthetics
B) Development of the germ theory
C) Discovery of multiple aseptic techniques
D) Demonstration of the benefits of preoperative education

Feedback: INCORRECT
Nursing knowledge has made important contributions to the perioperative care of the
client. Structured preoperative teaching and return demonstrations of postoperative
exercises have been shown to improve outcomes in such areas as pain management,
pulmonary function, length of stay, and the client's level of anxiety. The other contributions
listed were not based specifically on nursing assessments, but rather were physician
driven.
17.
The nurse taking a medication history preoperatively asks the client about allergies. Which
of the following is the most appropriate way of asking the client about this issue?
A) "Do any medications make you sick?"
B) "Do you have any medication allergies?"
C) "Have you ever had a problem with a medication or substance?"
D) "Have you ever had difficulty breathing after taking medication?"

Feedback: INCORRECT
"Have you ever had a problem with a medication or substance?" is a broad question that
may elicit more information from the client than the other styles of question. The nurse
needs to distinguish allergies from unpleasant side effects. For example, codeine may
cause nausea (a side effect) or hypotension and confusion (an allergy) in a client. The term
allergy can be confusing to some clients. Therefore the nurse will get more information
from the client by asking about any problems instead of being so specific.

18.
Surgical procedure permitting, in what position should the client be placed during the
immediately postanesthetic stage of recovery?
A) High-Fowler's
B) Semi-Fowler's
C) Supine with pillow
D) Side-lying, face down

Feedback: INCORRECT
Placement in a side-lying position with the face slightly down (recovery position) protects
the client from possible aspiration, and in this position the client's tongue falls forward.
Placement in a supine position may increase the possibility of aspiration. Both Fowler's
positions would fail to prevent an unconscious client from falling.
19.
The nurse conducts a partial or complete physical examination depending on the amount of
time available. The nursing assessment should complement the physical examinations
performed by the surgeon and anesthetist or anesthesiologist. Which of the following
assessments should the nurse perform immediately in the postanesthesia stage?
A) Airway, family support, and safety
B) Respiratory, neurological, and mental status
C) Anxiety, pain, and presence of coping mechanisms
D) Airway, level of consciousness, cardiovascular status, and safety

Feedback: INCORRECT
Clinical assessments to be completed immediately in the postanesthetic phase include
assessments for adequate airway, cardiovascular status, level of consciousness, pain, and
safety. Assessments of anxiety, presence of coping mechanisms, family support, and
emotional, and mental status are not a priority at this time.

20.
Encouraging the client to perform coughing exercises every 2 hours while awake is an
appropriate measure for the majority of postsurgical clients. After what surgical procedures
may coughing exercises be contraindicated?
A) Abdominal and spinal
B) Abdominal and thoracic
C) Thoracic, rectal, and eye
D) Eye, intracranial, and spinal

Feedback: INCORRECT
For clients who have had eye, intracranial, or spinal surgery coughing may be
contraindicated because of the potential increase in intraocular or intracranial pressure.
Coughing exercises are recommended after other surgeries to promote removal of
pulmonary secretions, if present.

SKIN INTEGRITY AND WOUND CARE (MODULE 17)
Pressure ulcers
o Impaired skin integrity related to unrelieved prolonged pressure.
o Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and or poor nutrition is at risk for pressure ulcers
o Pathogenesis of pressure ulcers
1. Pressure intensity - if pressure over capillary exceeds normal capillary pressure range
and the vessel is occluded then tissue ischemia can occur.
1. Pressure duration - low pressure over long period or high pressure over short period
1. Tissue tolerance -ability of tissue to endure pressure depends upon integrity of the
tissue and supporting structures
o Risk factors for pressure ulcer development
 Impaired sensory perception
 Impaired mobility
 Alteration in LOC
 Shear - the force exerted parallel to skin resulting from gravity and resistance between
the client and surface. (when head of bed is elevated and pt. slides down but skin is fixed
because of friction
 Friction
 Moisture
o Classification
 Stage 1 - intact skin with nonblanchable redness, usually over bony prominence. Darkly
pigmented may not have visible blanching
 Stage 2- partial thickness skin loss, involving epidermis, dermis, or both
 Stage 3 - full thickness tissue loss. Bone, tendon or muscle is NOT exposed
 Stage 4 - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or escar
may be present
 Unstageable - full thickness tissue loss which the base of ulcer is covered by slough
(yellow, tan, gray, green, or brown)and or eschar (tan, brown, or black) in wound bed. Until
enough slough/eschar is removed to expose base of wound the depth can not be
determined
o Wound classification
 Onset and duration
 Acute - wound that proceeds through an orderly and timely reparative process
that results in sustained restoration of anatomical and functional integrity
 Chronic - wound that fails to proceed through an orderly and timely process to
produce anatomical and functional integrity
 Healing process
 Primary intention - wound that is closed
 Secondary intention - wound edges are not approximated
 Tertiary intention - wound left open for several days, then wound edges are
approximated
o Wound repair
 Partial thickness - 3 components
 Inflammatory response
 Epithelial proliferation (reproduction) and migration
 Reestablishment of epidermal layers
 Full thickness wound repair
 Inflammatory phase
 Proliferative phase
 Remodeling
o Complications of wound healing
 Hemorrhage-
 Infection
 Dehiscence
 Evisceration
 Fistulas - abnormal passage between 2 or more organs or between organ and the
outside of the body.
o Risk assessment
 Norton scale - score five risk factors; physical condition, mental condition, activity,
mobility and incontinence. Score ranges from 5-20, lower score indicates risk for pressure
ulcer
 Braden scale
 Quantifies the risk factors for development of ulcers in chair and bed bound pt.
 For all pts.
 Use upon admission and every 24 hours unless indicated differently
 Sensory perception
 Ability to respond meaningfully to pressure related discomfort
 Completely limited (unresponsive)
 Very limited (responds only to painful stimuli)
 Slightly limited (responds to verbal commands but cant always
communicate discomfort)
 No impairment
 Moisture
 Degree to which skin is exposed to moisture
 Constantly moist
 Moist
 Occasionally moist
 Rarely moist
 Activity
 Degree of physical activity
 Bedfast (confined to bed)
 Chairfast
 Walks occasionally
 Walks frequently
 Mobility
 Ability to change and control body position
 Completely immobile
 Very limited
 Slightly limited
 No limitations
 Nutrition
 Usual food intake pattern
 Very poor
 Probably inadequate
 Adequate
 Excellent
 Friction and shear
 Problem (requires moderate to max assistance in moving)
 Potential problem (moves feebly or requires min assistance)
 No apparent problem

 Factors influencing pressure ulcer formation and wound healing
 Nutrition
 Tissue perfusion
 Infections
 Age
 Psychosocial impact of wounds
EVOLVE QUESTIONS
1.
When repositioning an immobile client, the nurse notices redness over a bony prominence.
When the area is assessed, the red spot blanches with fingertip touch, indicating:
A) A local skin infection requiring antibiotics
B) A stage III pressure ulcer needing the appropriate dressing
C) Sensitive skin that calls for the use of special bed linen
D) Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured
area

Feedback: INCORRECT
This observation is indicative of reactive hyperemia. This is not a local skin infection or a
stage III pressure ulcer. Not enough information is given to determine whether the client
has sensitive skin.
2.
Which type of pressure ulcer consists of an observable pressure-related alteration of intact
skin that may show changes in skin temperature (warmth or coolness), tissue consistency
(firm or beefy feel), and/or sensation (pain, itching) compared with an adjacent or
opposite area on the body?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Feedback: INCORRECT
In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented
skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin
areas. The skin will be warmer or cooler than other areas, with a change in consistency
and sensation. A stage II ulcer is characterized by partial-thickness skin loss involving the
epidermis and possibly the dermis. In stage III the ulcer appears as a full-thickness skin
loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not
through, the underlying fascia. In stage IV the ulcer shows as a full-thickness loss with
extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting
structures.

3.
When a wound specimen is obtained for culture to determine whether infection is present,
the specimen should to be taken from:
A) Necrotic tissue
B) Wound drainage
C) Drainage on the dressing
D) The wound after it has first been cleansed with normal saline

Feedback: INCORRECT
The wound should be cleaned with saline, then a culture specimen should be obtained from
the wound. Necrotic tissue, drainage on the dressing, and old wound drainage can harbor
old bacteria that may not necessarily be infecting the wound.

4.
Postoperatively a client with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the nurse sees that the
sutures are open and that pieces of small bowel are visible at the bottom of the now
opened wound. The correct intervention would be to:
A) Allow the area to be exposed to air until all drainage has stopped.
B) Place several cold packs over the area, with care taken to protect the skin around the
wound.
C) Cover the area with sterile saline-soaked towels and immediately notify the surgical
team; this is likely to indicate a wound evisceration.
D) Cover the area with sterile gauze; place a tight binder over the areas; ask the client to
remain in bed for 30 minutes because this is a minor opening in the surgical wound and
should reseal quickly.

Feedback: INCORRECT
In wound evisceration, the bowel extrudes from the body. The nurse should cover the
visible bowel with sterile saline-soaked towels and notify the surgical team. The area
should not be allowed to be exposed or to dry out. Cold packs and binders are not
acceptable options.

5.
Serous drainage from a wound is defined as:
A) Fresh bleeding
B) Thick and yellow drainage
C) Clear, watery plasma
D) Beige to brown and foul-smelling drainage

Feedback: INCORRECT
Serous drainage is clear, watery plasma. Bleeding is not serous. A thick, yellow drainage or
beige to brown drainage is indicative of an infection.

6.
For a client who has a muscle sprain, localized hemorrhage, or hematoma, application of
which of the following helps to prevent edema formation, control bleeding, and anesthetize
the body part?
A) Binder
B) Ice bag
C) Elastic bandage
D) Absorptive diaper

Feedback: INCORRECT
The application of cold will help constrict blood vessels, which will reduce swelling that
occurs with bleeding and edema formation in a muscle sprain. It also provides a numbing
effect. Binders and elastic bandages are not initial treatments for a sprain. A diaper would
not be used for a muscle sprain.

7.
Which of the following interventions is most appropriate in managing fecal and urinary
incontinence in a client?
A) Keeping the buttocks exposed to air at all times
B) Applying a large absorbent diaper that is changed when completely saturated
C) Using an incontinence cleanser, followed by application of a moisture barrier ointment
D) Cleansing frequently, applying an ointment, and covering the areas with a thick
absorbent towel

Feedback: INCORRECT
The use of an incontinence cleanser followed by application of a moisture barrier helps
protect the skin when a client is incontinent. A diaper should be used to collect the feces
and urine; however, the diaper should be changed as soon as it is wet—the nurse should
not wait until the diaper is completely saturated. The client's dignity should be maintained
by keeping the client covered.
8.
Which of the following is the best description of a hydrocolloid dressing?
A) A dressing containing a seaweed derivative that is highly absorptive
B) Premoistened gauze placed over a granulating wound
C) A dressing containing a débriding enzyme that is used to remove necrotic tissue
D) A dressing that forms a gel which interacts with the wound surface

Feedback: INCORRECT
The wound contact layer of a hydrocolloid dressing forms a gel as fluid is absorbed and
maintains a moist healing environment. It does not contain a débriding enzyme, a seaweed
derivative, or premoistened gauze.

9.
Placement of a binder around a surgical client with a new abdominal wound is indicated
for:
A) Collection of wound drainage
B) Reduction of abdominal swelling
C) Reduction of stress on the abdominal incision
D) Stimulation of peristalsis (return of bowel function) from direct pressure

Feedback: INCORRECT
The binder helps support the abdominal muscles and prevent stress on the incision. It
should be used with proper dressings that will collect wound drainage. A binder will not
reduce swelling and will not stimulate peristalsis.
10.
Application of a warm compress is indicated:
A) To relieve edema
B) For a client who is shivering
C) To improve blood flow to an injured part
D) To protect bony prominences from pressure ulcers

Feedback: INCORRECT
Warm compresses are used to improve blood flow to an affected part. Warm compresses
are typically not used for edema relief. A warm compress will not necessarily help with
shivering; extra blankets should be used instead. A warm compress will not protect from
pressure ulcers.
11.
Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood
flow, which results in tissue ischemia and ultimately tissue death. There are four stages of
pressure ulcer formation. The nurse observes partial-thickness skin loss involving the
epidermis and possibly the dermis. What stage of ulcer will the nurse document?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Feedback: INCORRECT
Partial-thickness skin loss involving the epidermis and possibly the dermis is classified as a
stage II ulcer. In stage I the ulcer appears as a defined area of persistent redness in lightly
pigmented skin or a darker red, blue, or purple area in darker pigmented skin, with no
open skin areas. In stage III the ulcer appears as a full-thickness skin loss involving
damage or necrosis of subcutaneous tissue that may extend down to, but not through, the
underlying fascia. In stage IV the ulcer appears as a full-thickness loss with extensive
destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

12.
There are three phases of wound healing. The nurse observes granulation tissue in a
client's pressure ulcer. What phase of wound healing is represented by granulation tissue?
A) Maturation phase
B) Hemostasis phase
C) Proliferative phase
D) Inflammatory phase

Feedback: INCORRECT
Tissue granulation occurs in the proliferative phase. Maturation is the final stage of wound
healing. Hemostasis occurs during the inflammatory phase.

13.
The nurse observes all wounds closely. At what time is the risk of hemorrhage the
greatest for surgical wounds?
A) Between 48 and 60 hours after surgery
B) Between 60 and 72 hours after surgery
C) During the first 24 to 48 hours after surgery
D) 7 days after surgery, when the client is more active

Feedback: INCORRECT
The risk is highest during the first 24 to 48 hours after surgery because of the possibility of
poor clot formation, slipped surgical suture, or trauma to a blood vessel by a foreign
object. The more time that passes after surgery, the greater the amount of healing, which
lessens the risk of hemorrhage.
14.
The autolytic, mechanical, chemical, and surgical methods that are often used during
wound management are all methods of accomplishing what?
A) Wound dressing
B) Wound cleansing
C) Wound débridement
D) Stimulation of growth factors

Feedback: INCORRECT
Methods of débridement include mechanical, autolytic, chemical, and surgical methods. All
of these methods share the common objective of removing nonviable, necrotic tissue.
Dressing, cleansing and stimulation of growth factors are not part of débridement.

15.
Several instruments are available for assessing clients who are at high risk for developing a
pressure ulcer. The Braden Scale is the most commonly used. What risk factors are
assessed using the Braden Scale?
A) Infection, hemorrhage, dehiscence, evisceration, and fistulas
B) Physical condition, mental condition, activity, mobility, and incontinence
C) Sensory perception, moisture, activity, mobility, nutrition, friction, and shear
D) Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture

Feedback: INCORRECT
The Braden Scale measures the following risk factors: sensory perception, moisture,
activity, mobility, nutrition, friction, and shear. The Norton Scale measures five risk
factors: physical condition, mental condition, activity, mobility, and incontinence. Infection,
hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing.
The factors that influence pressure ulcer formation and wound healing are nutrition, tissue
perfusion, infection, age, shear force and friction, and moisture.

16.
A 40-year-old client is a new paraplegic. The client is about to be discharged from the
rehabilitation center. Prevention of pressure ulcers has been an important part of the
client's education. In providing this education, the nurse should have included which of the
following guidelines?
A) The client should sit in chair for no longer than 3 hours.
B) The client should use a donut-shaped chair cushion.
C) The client should use a rigid cushion for full support.
D) The client should shift the weight in a chair every 15 minutes.

Feedback: INCORRECT
Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer
formation. The guideline for sitting up in a chair is to sit for 2 hours or less, but it is only a
guideline. The nurse should individualize activity for each client. Sitting on rigid or donut-
shaped cushions is contraindicated because they reduce blood supply to the area, which
increases the area of ischemia.

17.
During the skin assessment of an older adult client who had a stroke, the nurse noted a
reddened area over the coccyx. The next actions of the nurse for this client should include:
A) Massaging the reddened area and repositioning the client
B) Placing the client in Fowler's position and returning in 2 hours
C) Inserting a urinary catheter to prevent accumulation of moisture from urinary
incontinence
D) Repositioning the client off the coccygeal area and reassessing the area in 1 hour

Feedback: INCORRECT
Repositioning the client and reassessing the area in 1 hour is the most appropriate action
for the nurse. When pressure is relieved from an area, the blood flow returns and the
redness will disappear if no damage has occurred. This is the appropriate assessment.
Placement in Fowler's position would only increase pressure on the coccyx. Massaging of a
reddened area is not recommended because it could cause further injury if the tissue is
already compromised. Insertion of a urinary catheter will not relieve pressure on the
coccyx.
18.
The nurse is to collect a specimen for culture after assessing the client's wound drainage.
The best technique for obtaining the culture is to:
A) Cleanse the wound first.
B) Send the soiled dressing to the laboratory.
C) Swab from the outside skin edge inward.
D) Collect the specimen from accumulated drainage.

Feedback: INCORRECT
Cleansing the wound first and swabbing the granulation tissue will provide a culture
specimen that will show a more accurate picture of any causative organisms of wound
infection. Sending a soiled dressing and collecting a specimen from accumulated drainage
are not appropriate, because old and new drainage are mingled, and the drainage is
possibly growing organisms of its own and may not provide a true reflection of the wound
flora. Swabbing from the outer edge of the skin inward may introduce organisms into the
wound and contaminate the culture specimen.
19.
The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why is a
hydrogel dressing the best choice for this client?
A) It provides a wicking action.
B) It permits the nurse to view the wound.
C) It is soothing and reduces pain in the wound.
D) It can be used as a preventative dressing for high-risk friction areas.

Feedback: INCORRECT
Hydrogel dressings are gauze or sheet dressings impregnated with a water- or glycerin-
based amorphous gel. They are very useful in managing painful wounds because they are
very soothing to the client and do not adhere to the wound bed, so that dressing removal
causes little trauma. A hydrocolloid dressing may be used as a preventative dressing for
clients with high-risk friction areas. A self-adhesive, transparent film dressing allows for
viewing of the wound. The oldest and most common wound dressing is the gauze sponge,
which is especially useful in wicking away wound exudates.

20.
The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs
the client that the pad should be removed in 30 minutes. Why will the nurse return in 30
minutes to remove the pad?
A) A local response occurs.
B) A systemic response occurs.
C) Reflex vasodilation occurs.
D) Reflex vasoconstriction occurs.

Feedback: INCORRECT
If heat is applied for 1 hour or longer, blood flow is reduced by reflex vasoconstriction.
Vasoconstriction is the opposite of the desired effect of heat application. Reflex vasodilation
occurs when an application of cold is left on too long. Reflex vasodilation is the opposite of
the desired effect of cold application. Systemic response and local response are general
and vague terms.

OSTOMY CARE:
Ostomy- surgically created opening, a stoma is created to drain urine or feces.
 Location determines the consistency of the ostomy
o As you move up the large intestine you have to worry about dehydration
o Ileostomy byspasses the entire large intestine so stools are frequent and liquid, usually
on right side
 Same for colostomy of ascending colon
o Colostomy of transverse colon- results in a more solid, formed stool, rare
o Sigmoid colostomy releases near normal stool
o Jejunostomy- rare, need parenteral nutrition
 Three types of colostomy construction

o Loop colostomy
 Ex: higher rectal cancer
 Usually performed in emergency when the closing of colostomy is anticipated.
 A loop of bowel is pulled onto the abdomen, an external supporting device
(plastic rod) is placed under the loop to keep it from slipping back.
 The surgeon opens the bowel and sutures it to the skin of abdomen, the bowel
will have a proximal and distal end in one stoma
 The proximal end drains stool, the distal end drain mucus
o End colostomy
 One stoma formed from proximal end of bowel with the distal portion either
removed or sewn closed (hartmanns pouch) and left in cavity
o Double barrel
 Bowel is surgically severed in double barrel colostomy, the two ends are
brought out onto the abdomen.
 2 distinct stomas
 Proximal functioning stoma
 Distal nonfunctioning stoma
o Alternative procedures
 Ileoanal pouch anastomosis
 Used for pt that have ulcerative colitis or familial polyps
 Removal of the colon, the a pouch is created from the end of the small
intestine, and attaches to the anus
 The pouch serves as a collection of waster material, similar to the
rectum.
 Kock continent ileostomy
 Using the clients small intestine, detubularizing its cylindrical shape and
creating a spherical reservoir.
 Used in tx of ulcerative colitis
 Pouch has continent stoma, nipple type valve that is drained with
external catheter, which client places intermittently in the stoma
 Macedo-malone antegrade continence enema
 Used to improve continence in clients with fecal soiling associated with
neuropathic or structural abnormalities of anal sphincter
 3 cm flap of left colon is isolated
 A foley is placed on the surface of the flap creating a tubular passage
 Distal end of tube is made into a V shape to the skin flap
 Enema begins 7-10 days post op
 Psychological considerations
o Anxiety self esteem
o Coping body image
o Sexual relations diet

Nursing process and bowel elimination
ASSESSMENT
 Assessment includes a nursing hx, physical assessment of abdomen, inspection of fecal
characteristics, review of relevant test results
o Obtain diet and medication hx
o Identify signs and symptoms associated with altered elimination patterns
o Determine impact of underlying illness, activity patterns, and diagnostic tests on bowel
elimination patterns.
DIAGNOSIS
 Disturbed body image
 Ineffective health maintenance
 Risk for constipation
 Risk for diarrhea
PLANNING
 Select nursing interventions to promote normal bowel elimination
 Consult with dietitians and enteral stoma therapists
 Involve the client/family in designing nursing interventions
IMPLEMENTATION
o Promotion of normal defecation
 Sitting position
 Positioning on bedpan
 Privacy
 Acute care
o Medications
o Cathartics and laxatives
o Anti diarrheal agents
o Enemas
 Cleansing hypertonic solutions-
 Tap water soapsuds
 Normal saline oil retention
 Other
o Enema administration
o Digital removal of stool
o Inserting and maintaining a nasogastric tube because is decompresses the GI tract
 Continuing and restorative care
o Care of ostomies
o Irrigating a colostomy
o Pouching ostomies
 Pouch collects fecal material
 Effective pouching protects the skin, contains fecal material, remains odor free,
and is comfortable and inconspicuous

Decisions about pouching:
 Drainable vs. closed end
 One piece vs. two piece
 Filter vs. non-filter
 Stomahesive vs. durahesive barrier
 Clamp tail or velcro
 Spickett for urostomy
 Cut to fit
 Pre-cut
 Moldable
 Convex
 Change wafer every 4-5 days

EVALUATION
 Observe characteristics of stool and evaluate defecation pattern
 Observe for signs and symptoms of altered elimination
 Ask client to report perception of bowel elimination patterns following interventions
 Ask if the clients expectations are being met

CLASS NOTES

 Gastrointestinal tract
o Responsible for ingestion, digestion, and absorption of nutrients
o Storage and elimination of fecal waste
o Significant impact on fluid electrolyte balance
 Small intestine
o Duodenum - neutralizes acidic gastric contents
o Jejunum - major organ for nutrient absorption
o Ileum - nutrient absorption
 Diseases that may lead to ostomies
o Cancer familial adenomatous polyposis
o Diverticulitis inflammatory bowel disease (crohns ulcerative colitis)
o Congenital defects trauma
o Ischemic bowel disease
 Inflammatory bowel disease
o Systemic
o Not always confined to GI tract
o Innappropriate immune response to environmental triggers
o Leads to cascade of bodily responses that lead to disease symptoms
o Arthritis most common EM of IBD
 Fewer than 6 joints, involves ankles, knees, wrists, hips, and elbows
o Often subsides when bowel symptoms are in remission
Crohns disease Ulcerative colitis
Anywhere along GI tract Colon only
Abdominal pain, diarrhea, weight loss, and Diarrhea, rectal bleeding, weight loss
growth failure
Blood not visible if proximal disease Blood usually visible
Weight loss common due to malabsorption Some weight loss
Perianal disease Perianal disease uncommon
Some increase risk for cancer Significant increase risk for cancer
Surgery to remove disease but not curative Surgical removal of colon may be curative
except of EMs

 Post operative assessment
o Stomal viability
o Surrounding contours - ideally smooth surface, below the beltline
 Away from bony prominences, umbilicus or suture line
o Stomal height - may appear big due to inflammation
 Stoma should be moist and pink
 About 2.5cm
o Mucocutaneous suture line - the suture should be right up against skin
o Ileus - peristalis "goes to sleep"
o Anastomotic leak - renal failure, perforation, sepsis!
 Abdominal distention
 Will require systemic antibiotic therapy
EVOLVE QUESTIONS:
1.
Most nutrients and electrolytes are absorbed in:
A) The colon
B) The stomach
C) The esophagus
D) The small intestine

Feedback: INCORRECT
The small intestine (specifically the duodenum and jejunum) absorb most of the nutrients
and electrolytes. The ileum absorbs certain vitamins, iron, and bile salts. The colon absorbs
water, sodium, and chloride from the digested food that has passed from the small
intestine. The esophagus moves food from the mouth to the stomach.

2.
During the nursing assessment the client reveals that he has diarrhea and cramping every
time he eats ice cream. He attributes this to the cold temperature of the food. However,
the nurse begins to suspect that these symptoms might be associated with:
A) Food allergy
B) Irritable bowel
C) Lactose intolerance
D) Increased peristalsis

Feedback: INCORRECT
Lactose intolerance occurs in individuals who lack the enzyme needed to digest the milk
sugar lactose. Diarrhea and cramping following dietary ingestion are signs of lactose
intolerance. This is the most specific answer.

3.
In assessing a 55-year-old client who is in the clinic for a routine physical, the nurse
instructs the client about the need to provide a stool specimen for guaiac fecal occult blood
testing:
A) If the client notices rectal bleeding
B) If there is a family history of intestinal polyps
C) As part of a routine screening for colon cancer
D) If a palpable mass is detected on digital examination

Feedback: INCORRECT
Routine screening for colon cancer includes fecal occult blood testing. There does not need
to be a reason for routine screening, such as a family history, masses, or bleeding,
although these can indicate the need for further testing.

4.
Diarrhea that occurs with a fecal impaction is the result of:
A) A clear liquid diet
B) Irritation of the intestinal mucosa
C) Inability of the client to form a stool
D) Seepage of stool around the impaction

Feedback: INCORRECT
Although a mass of solid matter may obstruct the large intestine, liquid stool may leak
around the obstruction (impaction). A clear liquid diet is not the cause of the diarrhea, nor
is irritation of the intestinal mucosa. This type of diarrhea is not caused by the inability of
the client to form stool.

5.
A cleansing enema is ordered for a 55-year-old client before intestinal surgery. The
maximum amount of fluid used is:
A) 150 to 200 ml
B) 200 to 400 ml
C) 400 to 750 ml
D) 750 to 1000 ml

Feedback: INCORRECT
The maximum volume of enema to be administered to an adult is 750 to 1000 ml. An
infant is given 150 to 200 ml; a toddler, 250 to 350 ml; and a school-aged child, 300 to
500 ml. An adolescent is given 550 to 750 ml.

6.
During the enema the client begins to complain of pain. The nurse notes blood in the
return fluid and rectal bleeding. The nurse's next action is to:
A) Stop the instillation.
B) Slow down the rate of instillation.
C) Stop the instillation and measure vital signs.
D) Tell the client to breathe slowly and relax.

Feedback: INCORRECT
If bleeding occurs on enema administration, the nurse should stop the infusion, measure
vital signs, and notify the health care provider.

7.
A nurse trained to care for ostomy clients is:
A) A gastrointestinal therapist
B) A nurse practitioner.
C) An ostomy practitioner
D) A wound-ostomy-continence nurse

Feedback: INCORRECT
A wound-ostomy-continence nurse (WOCN) is a nurse with special training in caring for
ostomy clients. The other options are incorrect.

8.
Soon after the client's abdominal surgery the nurse includes in the plan of care which of
the following interventions, which is essential for promoting peristalsis?
A) Consumption of a high-fiber diet
B) Early ambulation
C) Restriction of fluid intake
D) Administration of large doses of opioids

Feedback: INCORRECT
Early ambulation is essential for maintaining peristalsis through improved abdominal
muscle tone and stimulation. Large doses of opioids may suppress peristalsis. The dosage
of opioid should be that which adequately controls pain with the fewest side effects. A
high-fiber diet is inappropriate immediately following surgery. The bowel is inflamed from
surgery. Restriction of fluids could contribute to constipation. Intake of fluids should be
started as soon after surgery as possible, once bowel sounds have returned.
9.
The nurse is instructing the client about the use of opioids for pain relief. Included in the
teaching is the fact that opioids may cause:
A) Headaches
B) Constipation
C) Hypertension
D) Muscle weakness

Feedback: INCORRECT
Constipation is a known side effect of opioids to which the client often does not become
tolerant. Headaches, hypertension, and muscle weakness are not known side effects of
opioids.
10.
When irrigating a colostomy, the nurse is sure to use which of the following equipment?
A) An enema set
B) A cone-tipped irrigator
C) A 50-ml irrigation syringe
D) A 16-French Foley catheter with a 30-ml balloon

Feedback: INCORRECT
Using a cone-tipped irrigator is important to prevent irritation of or injury to the stoma. It
prevents bowel perforation and backflow of irrigating solution. The other options are
inappropriate for colostomy irrigation because they could cause injury to the bowel mucosa
and/or allow backflow of the irrigating solution.

11.
A client who recently experienced a bout of diarrhea is requesting something to drink.
There is an order to force clear liquids to prevent fluid and electrolyte imbalance. The nurse
decides to give the client:
A) Ice cream
B) A cold fruit pop
C) A cup of hot coffee
D) Room-temperature bouillon

Feedback: INCORRECT
Hot and cold foods (options 1, 2, and 3) stimulate peristalsis, which can cause abdominal
cramping and further diarrhea. Thus room-temperature liquids are better tolerated.
Bouillon also contains some electrolytes that may prevent electrolyte imbalance. Ice cream
is not a clear liquid.

12.
The nurse is obtaining a client's medication history. Which of the following medications
may cause gastrointestinal bleeding? (Select all that apply.)
A) Aspirin
B) Cathartics
C) Antidiarrheal opiate agents
D) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Feedback: INCORRECT
Aspirin and NSAIDs may cause gastrointestinal bleeding. Antidiarrheal opiate agents slow
the motility in the gastrointestinal tract, and cathartics increase motility.
13.
To prevent the client from performing a Valsalva maneuver, the nurse might request a
stool softener for a client with which of the following conditions? (Select all that apply.)
A) Glaucoma
B) Hypotension
C) Cardiovascular disease
D) Risk for increased intracranial pressure

Feedback: INCORRECT
The Valsalva maneuver can increase intracranial pressure, which is undesirable. It can also
increase intraocular pressure and thus increase the risk for optic nerve damage.
Hypotension is not aggravated by the Valsalva maneuver, but the maneuver can increase
blood pressure, which could place a strain on the heart.
Correct Answer(s): A, C, D

14.
The nurse teaches clients with a new colostomy that they can eat whatever foods they like
but that which of the following foods typically produce gas and should be consumed
cautiously? (Select all that apply.)
A) Pasta
B) Beans
C) Garlic
D) Onions
E) Cauliflower

Feedback: INCORRECT
Foods affect clients differently. However, some foods appear to produce more gas than
others. Warning clients about these traditional gas producers will alert them to be aware of
the possible problem and allow them to make informed choices. Garlic and pasta are not
known to produce excessive gas.
Correct Answer(s): B, D, E
15.
The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10
days when which of the following occurs? (Select all that apply.)
A) The client feels nauseated.
B) The client oozes liquid stool.
C) The client has a rounded abdomen.
D) The client has continuous bowel sounds.

Feedback: INCORRECT
Nausea, liquid stool, and continuous bowel sounds are all symptoms of an impaction.
Liquid stool can seep around the impaction. If stool cannot exit, there is a backup of
gastrointestinal contents, which often results in nausea. Bowel sounds may be increased as
the body attempts to push the impaction forward. A rounded abdomen by itself may
indicate obesity or even ascites. For a rounded abdomen to be a symptom of an impaction,
distention must be present.
Correct Answer(s): A, B, D

16.
The nurse instructs the client to avoid which of the following foods, which could give a false
reading on the fecal occult blood test? (Select all that apply.)
A) Fish
B) Lasagna
C) Cranberry juice
D) Raw vegetables

Feedback: INCORRECT
Fish and some raw vegetables can produce false-positive results if consumed during the
collection of stool for occult blood testing. Although lasagna and cranberry juice are red,
they do not irritate the gastrointestinal tract so that bleeding occurs. The fecal occult blood
test measures blood in the stool and is unaffected by foods that are red.
17.
A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail."
Which nursing actions would be appropriate for the nurse to implement at this time?
A) Clamp the blue pigtail.
B) Attach suction to the blue pigtail.
C) Irrigate the large lumen with saline.
D) Position the blue pigtail at the level of the client's ear.

Feedback: INCORRECT
Irrigation determines the patency of the main sump drain. If it is obstructed, stomach
contents can and will exit via the blue pigtail. Positioning the blue pigtail above the level of
the stomach minimizes its becoming a drain. One should never clamp or apply suction to
the blue pigtail, because that would eliminate its function as an air vent that prevents the
gastric mucosa from being sucked into the sump's eyelets.
Correct Answer(s): B, D

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MEDICATION ADMINISTRATION (chap.

When a medication is administered to a client, a predictable chemical reaction

Before meals AC, ac

Twice a day BID, bid

At bedtime hs (hour of sleep)

After meals PC, pc

Whenever there is a need prn

Every morning, every am Qam

Every day, daily daily

Every 2 hours q2h

Every 6 hours q6h

Every 8 hours q8h

4 times a day QID, qid

Every other day every other day

Give immediately STAT

3 times a day TID, tid

Each teaspoon is 5 ml and 2 tablespoons is 6 teaspoons, so 5 × 6 = 30 ml.Points Earned: 1.0/1.0

ACTIVITY AND EXERCISE (chap. 37)

 Simple face mask

 Prevent air or fluid from reentering

EVOLVE QUESTIONS (NUTRITION)

Correct Answer(s): 1000

PREOPERATIVE (MODULE 16)

SKIN INTEGRITY AND WOUND CARE (MODULE 17)

 Three types of colostomy construction

Anywhere along GI tract Colon only

Blood not visible if proximal disease Blood usually visible

Weight loss common due to malabsorption Some weight loss

Perianal disease Perianal disease uncommon

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