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Week 1
PACU post-op bowel resection with a new colostomy for history of Crohn’s
disease:
Entry level nurses should know routine colostomy care/teaching as noted in IGGY book. The first action required when receiving a patient is confirming patient identification. Crohn’s Disease (CD) is a chronic inflammatory disease of the small intestine, colon, or both. Same as Ulcerative Colitis (UC), Crohn’s is a recurrent disease with periods of remissions and exacerbations. What are important assessment points for a patient with Crohn’s disease and what discharge teaching would you provide regarding management of Crohn’s disease? See page 1146-1149 in IGGY 10th edition. Assessment points include monitoring for manifestations of peritonitis, small bowel obstruction, and nutritional/fluid imbalances. These patients are at high risk for malnutrition, dehydration, and hypokalemia. Monitor output and daily weights as a decrease in either could indicate dehydration, which means additional fluids are a priority. Nutritional supplements may be needed in addition to a high-calorie, high-protein, high-vitamin, low-fiber diet. TPN or TEN may be needed for a patient with Crohn’s while hospitalized. 3,000 calories per day is indicated. A low-fiber diet is indicated for patients with Crohn’s as well as other GI diseases such as diverticulitis. Teaching should include to avoid GI stimulants such as alcohol and caffeinated beverages. Vit B12 injections may be needed. Fistulas are common with exacerbations and teaching for wound care is indicated if the patient has this complication. Dr. Blackburn Post-op abdominal surgery patients often have an NG placed for decompression of the stomach. This includes post-op colorectal cancer patients, who may also have a colostomy depending on procedure performed. Entry level nurses should know care of patients with an NG tube.
Try this practice question and provide a rationale for your response: A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take?
- Use a 22 gauge needle.
- Select a site on the client’s abdomen.
- Use the Z-track technique to displace the skin on the injection site.
- Observe for bleb formation to confirm proper placement. Answer: 2
- Not correct. For a subcutaneous injection, use a 25 to 27 gauge needle.
- CORRECT: For a subcutaneous injection, select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). For a subcutaneous injection, pinch a section of skin or pull the skin taut using the thumb and index finger. When administering enoxaparin do not expel the air bubble in the syringe. It’s nitrous oxide and allows the client to receive all the medication during the injection.
- Not correct. The Z-track technique for IM injections is used for medications that are irritating to the tissue, which includes pulling the skin and tissue taut. Firmly hold in this position while the needle is inserted and the medication is injected. Iron dextran is a medication administered using the Z-track technique. Some facilities require the Z-track technique for all IM injections. For IM, solution volume is usually 1 to 3 mL. The ventrogluteal site is preferable for IM injections and for injecting volumes exceeding 2 mL. If more than 3 mL is needed for the ordered dose, the medication will need to be given in two separate injections. The deltoid site has a smaller muscle mass and can only accommodate up to 1 mL of fluid.
- Not correct. Bleb formation confirms injection into the dermis, not into subcutaneous tissue. Intradermal are used for tuberculin (Mantoux) testing or checking for medication or allergy sensitivities. Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine-gauge needle (26 to 27 gauge) in lightly pigmented, thin-skinned, hairless sites (the inner surface of the mid-forearm or scapular area of the back) at a 5° to 15° angle. Insert the needle with the bevel up. A small bleb should appear. Do not massage the site after injection. A Mantoux (TB) test should be read 2-3 days after administration. A positive response indicates the client may have been exposed to the TB bacteria or dormant disease. 10mm or > induration is considered positive for exposure to or infection with TB. An induration of more than 5 mm is
● If using nitroglycerin translingual spray, one spray substitutes for one sublingual tablet when treating an anginal attack. ● Maintain a fresh supply of sublingual nitroglycerin. Store nitroglycerin in a light-resistant container. They will maintain potency up to five months. After five months the unused tablets should be discarded. Dr. Blackburn
hyperbilirubinemia and mom tested negative for rubella titer during pregnancy:
Topic-Phototherapy:
Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice. Jaundice normally appears on the head (especially the sclera and mucous membranes), and then progresses down the thorax, abdomen, and extremities. When phototherapy is implemented the newborn’s bilirubin should start to decrease within 4 to 6 hr after starting treatment. You noted a few, what other nursing interventions (best practices) are appropriate when caring for an infant receiving phototherapy? Nursing care for the infant receiving phototherapy includes: ● Keep the newborn undressed. For a male newborn, a surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ● Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas. ● Remove the newborn from phototherapy every 4 hr ○ Unmask the newborn’s eyes for feedings, checking for inflammation or injury. ● Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ● Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ● Check the lamp energy with a photometer following facility protocol. ● Turn off the phototherapy lights before drawing blood for testing. ● Monitor for adverse effects of phototherapy. ○ Dehydration: poor skin turgor, dry mucous membranes, decreased urinary output ○ Elevated temperature
○ Maculopapular skin rash: not a serious complication ○ Bronze baby syndrome is a complication (rare) in some infants with cholestatic jaundice when treated with phototherapy. With exposure to phototherapy lamps, infants develop a dark, gray-brown discoloration of skin, urine, and serum. ● The newborn’s bilirubin should start to decrease within 4 to 6 hr after starting treatment. Dr. Blackburn Topic- Rubella immunization: For rubella, immunization of clients who are pregnant is contraindicated because rubella infection can develop. These clients should avoid crowds and young children. Clients who have low titers prior to pregnancy should receive immunizations before becoming pregnant. For those already pregnant, the rubella vaccination is received postpartum due to the effects on fetus in utero. Clients should avoid pregnancy for 28 days after receiving the vaccine. Topic- Transferring: A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select all that apply and include a rationale for your response(s).
- Request assistance when repositioning a client.
- Avoid twisting your spine or bending at the waist.
- Keep your knees slightly lower than your hips when sitting for long periods of time.
- Use smooth movements when lifting and moving clients.
- Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. Answer: 1, 2, and 4.
- CORRECT: To reduce the risk of injury, at least two staff members should reposition clients. Prior to transferring clients, determine whether or not the client can assist with the transfer then seek assistance.
- CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury.
- When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back.
● Lack of sufficient insulin related to undiagnosed or untreated type 1 diabetes mellitus or nonadherence to a diabetic regimen ● Reduced or missed dose of insulin (insufficient dosing of insulin or error in dosage) ● Any condition that increases carbohydrate metabolism (physical or emotional stress, illness) ● Infection is the most common cause ● Increased hormone production (cortisol, glucagon, epinephrine) that stimulates the liver to produce glucose and decreases the effect of insulin Topic- ABGs: Try this practice question from category NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.45, PaO2 94, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid‑base imbalances?
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis Include a rationale for your response. Answer: 2
- Not correct. A client who is experiencing respiratory acidosis will have a decreased pH and an increased PaCO2. Possible causes of respiratory acidosis include anesthesia, pneumonia, COPD, ARDS, PE, and overdose.
- CORRECT: A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, early onset PE, mechanical ventilation, and fear.
- Not correct. A client who is experiencing metabolic acidosis will have a decreased pH and a decreased HCO3. Possible causes of metabolic acidosis include DKA, renal failure, dehydration, liver failure
- Not correct. A client who is experiencing metabolic alkalosis will have an increased pH and an increased HCO3. Possible causes of metabolic alkalosis include antacids, prolonged vomiting, and NG suctioning.
Expect comp exams to test knowledge of ABGs. You should be able to recognize ABGs for each type of acid/base imbalance as well as possible causes for each one. Dr. Blackburn Topic- DM: Type 1 DM is characterized by destruction of pancreatic beta cells. A person may be predisposed to develop DM Type 1 or Type 2 from genetics. Toxins and viruses can predispose an individual to diabetes by destroying the beta cells, leading to type 1 diabetes mellitus. Entry level nurses should know expected ABG values/causes for patients experiencing various acid/base disorders. Topic- Precautions: Try this practice question and provide a rationale for your response: The nurse is precepting a new nurse in the emergency department. Which of the following actions by the new nurse would require the preceptor to intervene?
- Implementing airborne precautions for a patient diagnosed with disseminated zoster (shingles)
- Implementing protective isolation for a patient receiving chemo experiencing neutropenia
- Implementing droplet precautions for a patient diagnosed with scabies complaining of itching.
- Implementing contact precautions for a patient with pediculosis and small red bumps on the scalp Answer: 3 would require follow-up. Droplet precautions are not indicated for patients with scabies. Treatment for scabies includes contact precautions, apply a 5% permethrin cream over the entire body (avoid face/head) to remain on the skin for 8 to 14 hr. Repeat permethrin in 1 week, wash bedding and clothing in hot water during this time. 1 would not need follow-up. Airborne precautions are appropriate for patients with disseminated zoster (shingles), varicella, TB, SARS/COVID, and measles (rubeola). See IGGY page 420 table 23-3. Question asked which pt should be put in a treatment room first, said the pt had a rash, indicative of shingles (airborne precaution)
- Require that all clients who have had previous suicidal ideation, plans, or attempts refill their medication every 2 weeks rather than monthly.
- Suggest that family and friends of previously suicidal clients know the client’s whereabouts at all times. Answer: 1, 2 Having resources such as a crisis phone line number and a specific prevention plan helps clients know what to do if they begin to feel they want to harm themselves. Trained crisis line employees will offer to send help first thing when the client calls. A No Harm contract is important if a patient has expressed suicidal ideation thoughts. Not all medications are lethal enough that access to a month’s supply should be limited. Further, such a limitation is likely to increase costs, which may increase the client's stress. Constant surveillance is unrealistic and potentially distressing to the client. Dr. Blackburn Topic- schizophrenia: Remember test plan reference is also needed as that is where you get the activity statements and category names. Patients with paranoid schizophrenia may experience alterations in thought (delusions). Assess the client for paranoid delusions, which can increase the risk for violence against others. If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others. When caring for patients with schizophrenia: ● Assess for paranoid delusions, which can increase the risk for violence against others. ● If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others ● Ask the client directly about hallucinations. Do not argue or agree with the client’s view of the situation. ● Appropriate comments by the nurse if the client is hallucinating would be “I don’t hear anything, but you seem to be feeling frightened.” ● Attempt to focus conversations on reality-based subjects. ● Provide prepackaged nutritious food because the client might not trust other food sources.
● Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations. Topic- lumbar puncture: Try this practice question from the NCLEX® Category: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures and provide a rationale for your response(s). A nurse is caring for a client who is post-procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.)
- Use the Glasgow Coma Scale when assessing the client.
- Assist the client to a supine position.
- Administer an opioid medication.
- Encourage the client to increase fluid intake.
- Instruct the client to perform deep breathing and coughing exercises. Answer: 2, 3, and 4.
- The Glasgow Coma Scale is used to assess a client’s level of consciousness and is not necessary following a lumbar puncture.
- CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture.
- CORRECT: The nurse should administer an opioid medication for a client’s report of headache pain.
- CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture.
- Coughing can increase ICP, which can result in an increase in the client’s headache. Monitor the puncture site for CSF leak. The “halo” sign, clear or yellowish ring surrounding a spot of blood indicates leakage of CSF and is a priority for follow-up. Dr. Blackburn Topic- Delusions: Clients with paranoid schizophrenia may experience delusions and hallucinations, which distorts reality and makes it difficult for the client to lead a normal life. See table 12.1 on page 195 Chapter 12 in your mental health textbook. The table lists types of delusions
Dr. Blackburn you are the nurse providing care for a client with history of CAD/HF who has digoxin toxicity and has Furosemide prescribed. Topic- Digoxin: Digoxin (monitor vital signs) is a medication that is sometimes prescribed to patients with HF. Monitor Na and potassium levels. Low serum K levels increase the risk of dig toxicity. Teach to check their pulse rate for 1 full minute before each dose and withhold dose/notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant, or irregular. Teach to monitor for s/s of dig toxicity (anorexia, n/v, visual disturbances, brady) and to report. Also instruct about reducing intake of sodium and avoiding excess fluids. Advise patient to eat foods high in potassium such as fruits (fresh, dried, juices), bananas, and vegetables including potatoes. Try this practice question and include a rationale for your response: The nurse on the med/surg unit is receiving report for the following clients. Which of the following should the nurse see first?
- Client with fracture of R femur receiving skeletal traction and needs pin care performed
- Client with history of pituitary adenoma has developed Cushing’s and is prescribed pasireotide
- Client with cast to LLE 3 hours ago is requesting more ice and medication for increased pain and warmth in LLE
- Client with exacerbation of HF taking digoxin, K level 3.6, Na 136, and IV fluids infusing at 50cc/hr Answer: 3 1 is not the priority. The client receiving skeletal traction for a fx will need pin care performed to prevent infection, but that is not the priority. 2 is not the priority. The client with Cushing’s prescribed pasireotide will need to be assessed but is not the priority. 3 is the priority. The client with a cast placed 3 hours ago and complaining of increased pain is the priority to see first. Painful areas under cast, hot spots, odor, or warmth can indicate infection and should be reported. The nurse should elevate the extremity and apply more ice. Pain with passive movement distal to the injury is an expected finding but
severe pain or pain unrelieved by narcotics could be a manifestation of compartment syndrome. 4 is not the priority. The client with HF prescribed digoxin will need assessed as K and Na levels are decreasing and could lead to serious complications if the values continue to decrease, but this client is not the first priority. The IV rate is appropriate for most patients with HF, any faster infusion could lead to overload complications including pulmonary edema. Always verify accuracy of IV infusion rate. Dr. Blackburn Topic- diuretics: Diuretics enhance the renal excretion of sodium and water as blood volume is reduced. Preload as well as systemic and pulmonary congestion is decreased in patients taking diuretics. Monitor for cerebral, neuromuscular, and intestinal changes in patients with hyponatremia and report if any present. Behavior and LOC changes (confusion/restless) are often noted in older adults experiencing hyponatremia. If Na levels drop too low, seizures as well as coma/death may occur. Report manifestations of hyponatremia and ototoxicity (tinnitus or hearing loss). (patient on lasix reports ringing of ears) Topic- interdisciplinary team: Interprofessional practice involves health care professionals across disciplines working together to provide appropriate care for patients. Try this practice question on interdisciplinary conferences and provide a rationale for your response: A nurse is participating in an Interprofessional conference for a client who has a recent C spinal cord injury. The client worked as a construction worker prior to his injury. Which of the following members of the interdisciplinary team should participate in planning care for this client? (Select all that apply.)
- Physical therapist
- Speech therapist
- Occupational therapist
- Psychologist
- Vocational counselor Answers: 1, 3, 4, 5. Rationale:
due to the narrow therapeutic range. Need to monitor CBC, serum electrolytes, renal function tests, and thyroid function tests during lithium therapy. ● Provide nutritional counseling. Stress the importance of adequate fluid and sodium intake. Encourage clients to maintain a diet adequate in sodium, and to drink 2,000 mL to 3,000 mL of water each day from food and beverage sources. Conditions that cause dehydration, such as exercising in hot weather or diarrhea, put client at risk for lithium toxicity and should be avoided. ● Instruct clients to monitor for manifestations of toxicity and when to contact the provider. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating. Topic- pediatrics: You learned about health promotion for adolescents in a previous course. Try this ATI practice question from the NCLEX® Category: Health Promotion and Maintenance, Health Screening and provide a rationale for your response: A nurse is providing anticipatory guidance to the caregiver of a 13-year-old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (Select all that apply.)
- Body mass index
- Blood lead level
- 24-hr dietary recall
- Weight
- Scoliosis Answer: 1, 4, 5.
- CORRECT: Recommend that the adolescent have a body mass index screening annually.
- Not correct. Blood lead level screenings are recommended for children at the age of 1 and 2 years, and for children between the ages of 3 and 6 years who have not previously been screened.
- Not correct. A 24-hr dietary recall is not a routine screening for an adolescent.
- CORRECT: Recommend that the adolescent have a weight screening annually.
- CORRECT: Recommend that the adolescent have a scoliosis screening annually. Dr. Blackburn Topic- bipolar:
When caring for clients with bipolar in manic phase we need to set limits and enforce boundaries. As noted in the mental health book staff continually set limits in a firm, nonthreatening, and neutral manner to prevent escalation of behavior and ensure safe boundaries. Topic- disaster triage: You learned about disaster triage in NUR265. Describe the disaster triage tag system. Green tags are the walking wounded; they are not the priority in a disaster. Non-urgent includes minor injuries where treatment can be delayed over 2 hours such as closed fractures, sprains, strains, abrasions, contusions. The urgent category for disaster triage is a yellow tag and includes major injuries that require treatment. These major injuries include open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours. For urgent category with ER triage this includes patients that need attention quickly but not life-threatening injuries. Severe abdominal pain, displaced or multiple fractures/soft tissue injuries, and pneumonia in older adults would be examples of urgent category patients. Individuals with immediate life-threatening injuries get a red tag, which is the emergent category for disasters. The emergent category is the same for disaster and ED triage. This is the category for those with immediate threat to life: manifestations of stroke, respiratory distress/airway obstruction, shock, chest pain/diaphoresis, active hemorrhage (internal bleeding may present as flank pain), unstable vital signs, and cardiac instability. Clothing may need to be cut away with scissors, if contaminated by hazardous material don’t touch even with gloves. Use tongs/forceps to handle clothing and dispose of in biohazard waste. The black tag, or expectant level, in disasters is for those patients expected to die. Black-tagged patients are those with massive head trauma, extensive full-thickness burns, and high cervical spinal cord injury requiring mechanical ventilation. These patients are not the priority in a disaster. The rationale for this seemingly heartless decision is that limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expenses of many others. Dr. Blackburn Priority pt has second degree burn to the chest and arm with rr greater than 30 Topic- bipolar:
- CORRECT: Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring intervention with IV fluid therapy.
- Apical pulse rate of 62/min is not a manifestation of hypovolemia. Dr. Blackburn
Week 3
you are the nurse providing care for an older adult with hearing impairment who is receiving chemotherapy and has developed anemia. Topic- Chemotherapy: Complications of chemotherapy treatment include: ● Low WBC count or neutropenia ● Bleeding caused by thrombocytopenia or low platelet count ● Anemia or low RBCs. Nursing best practices include monitoring WBC, absolute neutrophil count, platelet count, Hgb, and Hct for these patients. You should know normal values for WBC, Platelets, Hgb, and Hct so you can recognize abnormal levels. Also, assess these clients for bruising and bleeding gums. Protection from infection is a priority for patients receiving chemotherapy. For inpatients, a private room is desired or cohort only with a patient that also needs protective measures. Client education includes avoiding crowds and people that are ill as well as good hand hygiene. Understanding delegation is necessary for registered nurses. Expect all comps and NCLEX to test on delegating. The LaCharity book is a great resource with important information about delegation in assigned reading. What are examples of tasks that can be delegated to UAPs and what type of tasks can be delegated to LVNs? Topic- delegation: Nurses can only delegate tasks appropriate for the skill and education level of the health care team member who is receiving the assignment. RNs cannot delegate the nursing process, client education, or tasks that require clinical judgment.
Examples of tasks nurses may delegate to LVNs and UAPs (provided the facility’s policy and state’s practice guidelines permit) TO LVNs ● Monitoring findings (LVNs can collect data for input to the RN ’s ongoing assessment/care plan) ● Reinforcing client teaching from a standard care plan created by an RN (LVNs cannot do initial teaching or care planning) ● Performing tracheostomy care ● Suctioning ● Finger stick ● Checking NG tube patency ● Administering enteral feedings ● Inserting a urinary catheter ● Administering routine medication (excluding IV medication in some states) ● Wound care/wound vac/dressings TO UAPs Activities of daily living (ADLs) ● Bathing ● Grooming ● Dressing ● Toileting ● Ambulating (not first time up after procedure or surgery) ● Transferring ● Feeding (not for patients with swallowing precautions/no tube feedings) ● Positioning Routine tasks ● Bed making ● Specimen collection ● Intake and output ● Vital signs (recheck is fine but not first set after procedure or surgery) ● Catheter care Dr. Blackburn Topic- hearing aids:
