Chapter 21, 22, 40, 43, and 45 Critical Critical Judgement Questions and Examination Challenges Flashcards Preview

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Flashcards in Chapter 21, 22, 40, 43, and 45 Critical Critical Judgement Questions and Examination Challenges Deck (23)
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1

p. 365, Physiological Integrity
Which pathologic description of a client’s tumor does the nurse interpret as being the “most malignant” or “high grade” cancer?
A. Poorly differentiated; mitotic index = 20%, euploid
B. Moderately differentiated; mitotic index = 50%, euploid
C. Undifferentiated; mitotic index = 50%, aneuploid
D. Highly differentiated; mitotic index = 10%, aneuploid

Answer: C

Rationale: Tumors that closely resemble normal cells are “less malignant,” and those that have few normal cell features are “more malignant.” Thus, those that are euploid are less malignant and those that are aneuploid, with abnormal numbers or structures of chromosomes, are more malignant. Less malignant cells are highly differentiated, and more malignant cells are poorly or undifferentiated. Cells that divide faster (have a higher mitotic index) are more malignant.

2

p. 369, Health Promotion and Maintenance
A 65-year-old client tells the nurse she does not have mammograms because there is no history of breast cancer in her family. What is the nurse’s best response?
A. “You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk for you.”
B. “Performing breast self-examination monthly at home is sufficient screening for someone with your family history.”
C. “Because your breasts are no longer as dense as they were when you were younger, your risk for breast cancer is now decreased.”
D. “Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age.”

Answer: D

Rationale: Only a small percentage of cancers, including breast cancers, are hereditary or familial. The far more critically important risk factor for breast cancer in women is advancing age. Although performance of monthly self-breast examination is good, for a woman of this age, it should be done in conjunction with a yearly mammogram.

3

p. 377, Psychosocial Integrity
The client receiving brachytherapy with implanted radioactive “seeds” for prostate cancer asks the nurse when these seeds will be removed. What is the nurse’s best response?
A. “The half-life of radiation in these seeds is so short that it is not necessary to remove them.”
B. “They will only be removed if their presence is painful or leads to an enlarged prostate gland.”
C. “When we know for certain that all cancerous cells have been killed, the seeds will be removed.”
D. “The seeds are small enough to be absorbed by your body and excreted in the urine or stool.”

Answer: A

Rationale: The seeds are small and painless. The half-life of the radiation source is less than 2 weeks. Thus, it is not necessary for the seeds to be removed because they pose no health hazard to the client or anyone else. They are neither absorbed nor excreted by the body.

4

p. 383, Physiological Integrity
The client receiving high-dose chemotherapy who has neutropenia asks the nurse whether he and his wife can have sexual intercourse while he is receiving chemotherapy. What is the nurse’s best response?
A. “No, this activity will increase the side effects of the chemotherapy.”
B. “No, the danger of impregnating your wife is too great.”
C. “Yes, as long as you feel like it and use a condom.”
D. “Yes, if you do not have an infection.”

Answer: C

Rationale: Many people do not feel well enough to have sexual intercourse during the months they are taking chemotherapy. This activity is fine as long as the client takes precautions to limit chemotherapy drug exposure to his partner and protects himself from infection and trauma. Wearing a condom reduces chemotherapy drug exposure to his partner (as a result of any drugs entering the seminal fluid or are in the urethra from presence in the urine) and reduces his risk for developing an ascending urinary tract infection.

5

p. 387, Health Promotion and Maintenance
Which precaution is most important for the nurse to teach the client who has chemotherapy-induced peripheral neuropathy?
A. Avoid taking aspirin or any aspirin-containing products.
B. Use a bath thermometer to check bath water temperature.
C. Do not use mouthwashes that contain alcohol or glycerin.
D. Bathe daily using an antimicrobial soap or gel.

Answer: B

Rationale: Peripheral neuropathy reduces the ability to discriminate temperature sensation. It is very easy for a person with neuropathy to be unaware of water temperature and to become injured as a result of water for bathing or showering being too hot. Aspirin, although important to avoid when platelets are low, is not contraindicated with peripheral neuropathy. Alcohol or glycerin mouthwashes are contraindicated for mucositis, not peripheral neuropathy. Bathing with an antimicrobial soap helps prevent infection but does not prevent injury.

6

p. 394, Safe and Effective Care Environment
Which change in health status indicates to the nurse that the client's superior vena cava syndrome is worsening?
A. The client’s systolic blood pressure is rising, and the diastolic pressure is decreasing.
B. The client’s severe nausea and vomiting no longer responds to antiemetics.
C. The client has experienced four nose bleeds in the past 2 days.
D. Pedal edema is now present.

Answer: C

Rationale: With superior vena cava syndrome, blood flow through the vena cava is compromised as a result of tumor growth. As blood backs up in the venous system drained by the superior vena cave, pressure in the veins increases and nose bleeds (epistaxis) occur easily and more frequently. The increased venous pressure would not increase systolic pressure. Response to antiemetics is not affected by superior vena cava syndrome. Pedal edema could occur in response to a blockage in the inferior vena cava but not the superior vena cava.

7

p. 374, Ethical/Legal
Mrs. W. is an 80-year-old woman who has undergone exploratory surgery for an acute bowel obstruction. She had been relatively healthy, although growing more frail in recent years, and recently began to need home oxygen intermittently for chronic lung disease. Persistent abdominal pain and vomiting brought her to the emergency department. She lives alone, in an assisted living apartment, near her daughter Joan, who provides some additional assistance with grocery shopping, bill paying, etc. Mrs. W. has just been admitted to the ICU after surgery, where she is expected to remain intubated and mechanically ventilated overnight. The surgeon and Mrs. W’s daughter are talking outside of her room. You join the conversation in time to hear the surgeon explain that a large, disseminated cancer was found as the cause of the obstruction; he removed as much as he could but was not able to resect all of the cancer. Joan responds, “I was afraid of this. Whatever you do, don’t tell my mother it was cancer —she’ll never be able to cope with that. Please, just tell her that it was a benign tumor and you took it out.” The surgeon looks uncertain but nods and then leaves the bedside. Joan turns to you and says, “Tell the other nurses—nobody can say it was cancer.”

1. What, if anything, should you say to Joan at this point?

It is now the next day. As expected, Mrs. W. has remained stable through the night and has been successfully extubated. She is still somewhat sleepy and has not asked any questions about her surgery. When Joan comes in to visit, she pulls you aside and says, “No one told her about the cancer, right?”

2. How should you respond to Joan now?
3. Review the ethical principles in chapter 1. What ethical principle(s) are at risk or in play with this situation?

1. What, if anything, should you say to Joan at this point?
The nurse in this situation would be aware of the stress Joan is under, both from the ongoing caregiving responsibilities she bears and the news of her mother’s cancer. Because Mrs. W. is likely to be quite somnolent from the anesthesia and pain medicine and will not be able to talk until she is extubated in the morning, there is no need to resolve the issue of what to tell Mrs. W. at this moment. The nurse’s best response would be to reassure Joan that there will be time tomorrow to talk about what to tell her mother, that Mrs. W. will be sleepy through the night and the focus of her care will be to keep her comfortable, monitor vital signs, and evaluate her respiratory status. The nurse should also begin discussions with the rest of the care team, including the surgeon and other nursing staff, to form a plan for what to tell Mrs. W. and her daughter in the morning.

2. How should you respond to Joan now?
It is becoming more likely that Mrs. W. might, as she becomes more awake, ask questions about her condition. You cannot intentionally deceive Mrs. W by giving her false information, but you are also obligated to address duties to be truthful without imposing avoidable harm on both Mrs. W and her daughter. Joan is still anxious about how her mother will cope with the information about her diagnosis. First, assure Joan that no one has discussed the diagnosis. Then gently explain that it would not be acceptable to lie to her mother if she directly asks about her diagnosis but that the treatment team (doctors and nurses) will work with Joan to develop a plan for how and when to discuss Mrs. W.’s condition with Joan and her mother.

3. What ethical principle(s) are at risk or in play with this situation?
The principle of veracity (truth telling) imposes a relatively absolute duty on you as the nurse to refrain from intentionally deceiving patients. However, because you also have duties of nonmaleficence (avoid harm), you must avoid simply revealing blunt truth without attention to the consequences. This often requires very careful and early anticipatory planning so that patients can be provided with truthful information in a considerate and caring environment, with support persons in attendance. In addition, you also have duties to the patient’s family member to avoid increasing their distress. Ignoring their concerns and being insensitive to their needs would definitely increase their stress unnecessarily.

8

p. 801, Safe and Effective Care Environment
Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the health care provider?
A. Pain in the right hip with limited range of motion
B. Slow capillary refill in the toes of the right foot
C. Yellow appearance of the roof of the mouth
D. Facial drooping on the right side

Answer: D

Rationale: All current assessment findings are important. However, the pain in the hip, the slow capillary refill, and the yellow appearance of the roof of the mouth are related to the crises and are expected. The facial drooping as a new finding indicates the possibility of reduced brain perfusion and stroke. This dew development requires immediate attention and intervention.

9

p. 806, Health Promotion and Maintenance
Which intervention is most important for the nurse to teach the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency?
A. Use a soft-bristled toothbrush.
B. Drink at least 3 liters of liquids per day.
C. Wear gloves and socks outdoors in cool weather.
D. Exercise slowly and only on the advice of your physician.

Answer: A

Rationale: The other interventions focus on preventing venous stasis, clot formation, and myocardial infarction. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding.

10

p. 809, Physiological Integrity
The blood of a client who has chronic myelogenous leukemia shows a high percentage of blast cells and promyelocytes. What is the nurse’s correct interpretation of this test result?
A. The client’s risk for infection is decreasing.
B. The disease has become more aggressive.
C. The drug therapy for the disease is effective.
D. The type of leukemia is now lymphocytic rather than myelogenous.

Answer: B

Rationale: The leukemia is progressing and the drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course during which the patient may have mild symptoms and respond to standard treatments. The bone marrow usually shows less than 10% blast cells at this time. The accelerated phase features spleen enlargement and progressive manifestation, such as intermittent fevers, night sweats, and unexplained weight loss. The patient usually does not respond to standard treatment, and the bone marrow may contain 10% to 30% blast cells and promyelocytes. The blast phase indicates transformation to a very aggressive acute leukemia. The bone marrow contains more than 30% blast cells. The promyelocytes and blast cells commonly spread to other tissues and organs. The leukemia becomes more similar to acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.

11

p. 814, Safe and Effective Care Environment
The client is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the client’s skin on the palms of the hands and the soles of the feet. Which additional assessment data supports the nurse’s suspicion of possible graft-versus-host disease (GVHD)?
A. The client’s temperature is slightly below normal.
B. Today’s platelet count is 5,000/mm3 and the WBCs are low.
C. The client has had 6 to 10 watery stools daily for 3 days.
D. The client’s urine output is less than 800 mL in 24 hours.

Answer: C

Rationale: GVHD occurs when the immunocompetent cells of the donated marrow recognize the patient’s (recipient) cells, tissues, and organs as foreign and start an immunologic attack against them. The tissues most susceptible are the skin, intestinal tract, and liver. The earliest manifestation of gastrointestinal involvement for GVHD is large-volume watery diarrhea. The temperature is unaffected. The fact that the urine output is low is related to dehydration from diarrhea, not kidney damage by GVHD.

12

p. 826, Safe and Effective Care Environment
The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse’s best first action?
A. Call the blood bank.
B. Take and record the client's vital signs.
C. Stop the transfusion and keep the IV open.
D. Document the observation as the only action.

Answer: B

Rationale: Clients with AB negative blood types can receive O negative blood because they do not have antibodies against this type of blood. Therefore, the transfusion does not need to be stopped nor does the blood bank need to be notified. The transfusion can proceed. Because the nurse is seeing the client for the first time since the transfusion was initiated, the client’s vital signs need to be assessed rather than just documenting the observation.

13

p. 802, Ethical/Legal
A 27-year-old African-American man in sickle cell crisis is a patient on your unit. During report, one of the nurses from the previous shift mentions that she withheld the regularly scheduled IV opioid pain medication during the night because she had taken care of this patient a year ago and believes that he is a “drug seeker.”
1. What is your first action?
2. How should you approach your colleague?
3. Can a patient with sickle cell disease become addicted to opioids?
4. What can you do to prevent an incident like this one from happening again?

Suggested responses:

1. What is your first action?
Stop report and go and assess the patient for pain and administer the prescribed scheduled opioid. The pain during crisis is intense. Pain medication, including opioids, must be given on a scheduled basis and not as needed, and they should not be withheld.

2. How should you approach your colleague?
After you have seen to your patient’s comfort, remind her that unless there is a physiologic danger, such as severe respiratory depression, she is legally required to administer the prescribed opioid regardless of her beliefs. Determine whether she assessed the patient for pain and what, for this episode, not the patient’s behavior a year ago, convinced her that the pain is not real.

3. Can a patient with sickle cell disease become addicted to opioids?
It is possible for any patient with chronic pain that may have acute exacerbations to become addicted to opioids. However, this should never be assumed. Even if addiction did occur, the pain is real and must be appropriately managed, including the use of opioid analgesics.

4. What can you do to prevent an incident like this one from happening again?
Speak to the nurse manager and the patient’s health care provider about the incident. It is likely that this nurse does not understand the pathophysiology of sickle cell crisis or its management. There may be other nurses who have similar views. Arrange for a sickle cell disease and pain specialist to hold mandatory inservices on this topic for the entire staff on this unit.

14

p. 813, Safety; Teamwork and Collaboration
The patient is a 44-year-old chemical plant foreman who developed acute myelogenous leukemia 6 months ago. His initial therapy was successful, and he is scheduled to have a stem cell transplant (bone marrow) with his identical twin brother as the donor. His brother lives in the same city and is a professor at a local university. The patient is very grateful that his brother will donate bone marrow and states that he is certain that he has no risk for infection during the procedure because his brother is his identical twin.
1. What type of class of stem cell transplant would this procedure be considered?
2. Is the patient correct in assuming that he has no risk for infection because the donor is his twin brother? Provide a rationale for your response.
3. Which, if any, complications of stem cell transplantation are reduced or eliminated by having an identical sibling donate the stem cells?
4. Which, if any, complications (and why) are still possible even with a donor who is an identical sibling?

Suggested responses:

1. What type of class of stem cell transplant would this procedure be considered?
When the donor is an identical sibling, all major and minor tissue antigens are a perfect match, not just the six standard major ones. Therefore, this is considered a syngeneic transplant.

2. Is the patient correct in assuming that he has no risk for infection because the donor is his twin brother? Provide a rationale for your response.
No, the patient is not correct. The patient will still have to undergo a conditioning regimen to clear his own, potentially leukemic, cells. Thus he will still be profoundly immunosuppressed and at great risk for infection unless and until his brother’s stem cells properly engraft and grow in his body.

3. Which, if any, complications of stem cell transplantation are reduced or eliminated by having an identical sibling donate the stem cells?
The risk for GVHD is greatly reduced, although not completely eliminated, because the transplanted stem cells are identical to his own cells. The risk for veno-occlusive disease is likewise greatly reduced.

4. Which, if any, complications (and why) are still possible even with a donor who is an identical sibling?
In addition to infection, other pancytopenia problems can occur until full engraftment. The patient will be at risk for bleeding complications and may need both red blood cell and platelet transfusions after transplantation. It is possible that engraftment may not occur for many reasons, the most common of which is insufficient stem cells transplanted. Although HSCT can help cure leukemia, it is still possible that not all cancerous bone marrow cells were killed and could come back.

15

p. 818, Prioritization, Delegation, and Supervision
The patient is a 52-year-old woman who has undergone an autologous stem cell transplantation for non-Hodgkin’s lymphoma. She is recovering, and her white blood cell count is improving but still very low. She remains on neutropenic precautions. The LPN reports that the patient’s heart rate, respiratory rate, temperature, and blood pressure are all elevated.
1. Which vital sign finding would you report to the health care provider immediately and why?
2. You must assign an unlicensed assistive personnel (UAP) to help care for this patient. Of the four UAPs available, one is newly pregnant and has worked on this unit for 3 years, one has had cold symptoms for 3 days, one has not yet cared for a patient on neutropenic precautions, and one has a fear of people with cancer. Which UAP should you avoid assigning to this patient? Provide a rationale for your choice.
3. A nursing student tearfully reports to you, “I took some flowers into the patient’s room to cheer him up and he told me that he didn’t think he was supposed to have flowers. I took them out of the room right away and then I realized I had made a mistake.” How should you respond to this student?
4. The student asks you whether a book still wrapped in shrink wrap just now brought in by a friend of the patient can be taken to the patient’s room. How will you help the student know what to do in this situation?

Suggested responses:

1. Which vital sign finding would you report to the health care provider immediately and why?
The temperature elevation, no matter how slight, in a patient with neutropenia indicates infection until it has been ruled out. This elevation should be reported immediately, and you need to take the standard neutropenic interventions of full assessment, obtaining appropriate specimens for culture, obtaining chest radiography, and starting antibiotic therapy.

2. You must assign an unlicensed assistive personnel (UAP) to help care for this patient. Of the
four UAPs available, one is newly pregnant and has worked on this unit for 3 years, one has had cold symptoms for 3 days, one has not yet cared for a patient on neutropenic precautions, and one has a fear of people with cancer. Which UAP should you avoid assigning to this patient? Provide a rationale for your choice.
Assign the UAP who is newly pregnant and very experienced to assist with this patient. The patient’s possible infection is not harmful to the pregnant UAP because the infection is most likely from overgrowth of the patient’s normal flora. Infection in a patient with neutropenia can lead to sepsis and death very quickly. Therefore, an experienced and healthy caregiver is critical. The UAP who fears people with cancer may let his or her fear overshadow the ability to provide appropriate care. If this person fears cancer, he or she may also fear infection. In fact, it may be appropriate to request that this UAP be transferred to a unit that does not include people with cancer in its usual population.

3. A nursing student tearfully reports to you, “I took some flowers into the patient’s room to
cheer him up, and he told me that he didn’t think he was supposed to have flowers. I took them out of the room right away, and then I realized I had made a mistake.” How should you respond to this student?
Acknowledge the student for taking responsibility for the error. Helping the student to feel comfortable in reporting errors rather than hiding mistakes is essential for patient safety. Then go with the student to explain the situation to the nursing instructor so that the student can be counseled and procedures reviewed. Suggest to the instructor that the incident be used as a “teachable moment” and carefully shared with the other students. Suggest that the students discuss some of the ways patients with neutropenia can be protected from infections during hospitalization.

4. The student asks you whether a book still wrapped in shrink wrap just now brought in by a
friend of the patient can be taken to the patient’s room. How will you help the student know what to do in this situation?
A book in shrink wrap could have potential organisms on it. However, the shrink wrap is waterproof. Tell the student to cleanse the shrink wrap with an alcohol-based hand rub and then remove the shrink wrap before giving the book to the patient. Although the book and its jacket are not sterile, they most likely have been handled only by machines in the printing process and are unlikely to convey pathogenic microorganisms (or any other organisms) to the patient.

16

p. 891, Physiological Integrity
When providing discharge teaching to a client after a lumbar laminectomy, the nurse teaches the client to engage in which activities?
A. Evening showers with hot water
B. Vigorous stair climbing
C. Return to work within 1-2 weeks
D. Daily walking

Answer: D

Rationale: Daily, low-intensity activity promotes recovery after back surgery. Stair climbing is avoided initially because of the physical stress on trunk muscles. Showers are avoided initially until the surgical incision is closed. A return to work needs additional consideration to evaluate risks to recovery, particularly related to limitations in static positions or lifting.

17

p. 897, Safe and Effective Care Environment
A client was admitted this morning with an incomplete cervical spinal cord injury and is placed in a halo fixator. Halo fixation is used to reduce motion of the cervical spine. Which assessment finding will the nurse report immediately to the health care provider?
A. A new-onset heart rate of 48 beats/min
B. Mean arterial pressure of 90 mm Hg
C. Pain level of 2 on a 0-to-10 pain scale
D. Oxygen saturation of 95% on room air

Answer: A

Rationale: Bradycardia is a sign of spinal shock. This symptom is a result of the interruption of sympathetic nervous system stimulation associated with the cervical spinal neurons. A mean arterial pressure of 90 mm Hg and oxygen saturation of 95% indicate normal physiology and no concerning changes in airway or circulation. A pain level of 2 indicates pain that is well controlled at a value less than 4 on a 0 to 10 scale.

18

p. 901, Safety; Evidence-Based Practice; Teamwork and Collaboration
A 52-year-old man who has had a T-10 spinal cord injury for 10 years is admitted for septicemia. He has a 3 × 2–centimeter discoloration on his left buttock that is classed as an unstageable pressure ulcer. He has an indwelling urinary catheter. The patient has been living alone and states that he has no family or friends. He has had a variety of health problems and wishes he would die. An antidepressant was prescribed for the patient 3 years ago, but he does not take it because it makes him tired.
1. What priority problems does this patient have at this time? Which problems need immediate action and why? What other data do you need to help formulate your answer?
2. With what members of the interdisciplinary and nursing team should you collaborate to provide quality care for this patient?
3. What may be causing the patient’s septicemia? What are the evidence-based interventions for the care of patients with septicemia? Use a reliable electronic database to help you answer this question.
4. Use the SBAR method to communicate your concerns about this patient to another nurse who will be continuing his care.

Suggested responses:

1. What priority problems does this patient have at this time? Which problems need immediate action and why? What other data do you need to help formulate your answer?
Priority problems include the potential for serious perfusion impairment leading to shock from infection (septic shock), impaired mobility from long-standing spinal cord injury, and risk for hazards of immobility such as venous thromboembolism. Untreated depression and potential risk for self-harm also needs additional assessment; a validated tool to screen for depression can be used or consultation with psychiatric services.
Infection with possible sepsis needs immediate action. The immediate priority is administration of an antibiotic for infection. Administration of the prescribed antibiotic in septic patients must occur within 2 to 4 hours of diagnosis for best outcomes and to reduce sepsis-related death. Septicemia can lead to circulatory collapse; intravenous (IV) access must be established and fluids administered. Monitor airway and breathing because these problems may occur in tandem with low perfusion conditions such as septic shock.
Additional data needed includes information about the condition of the pressure ulcer, the quality of urine (signs of infection, including cloudiness or odor), white blood cell (WBC) count and differential (elevated WBCs and neutrophilia would suggest infection), and urinalysis (a positive leukoesterase and nitrogen would suggest urinary tract infection [UTI]).

2. With what members of the interdisciplinary and nursing team should you collaborate to provide quality care for this patient?
Immediate collaboration with the provider is necessary to obtain antibiotics and fluid replacement. Consider consultation with an infectious disease provider or pharmacist for the selection and safe administration of antibiotics. Collaborate with physical and occupational therapy to maintain mobility and independent function. A case manager can provide transitional care after septicemia resolves. Consult with psychiatric or social services for mood disorders and the management of depression.

3. What may be causing the patient’s septicemia? What are the evidence-based interventions for the care of patients with septicemia? Use a reliable electronic database to help you answer this question.
The two most likely sources for infection are the patient’s pressure wound and catheter-related UTI. The wound is unstageable and may have related abscess or even osteomyelitis. Indwelling catheters and the biofilm they acquire over time serve as a impetus for infecting organisms. Pathogenic organisms can travel from the wound or bladder to the bloodstream, causing sepsis.
We recommend using The Surviving Sepsis Campaign (survivingsepsis.org) to guide the management of patients with severe sepsis or septic shock. Routine screening of patients for potentially serious infections is the first step in a “sepsis bundle.”
Provide protocolized, quantitative fluid resuscitation of patients with sepsis-induced tissue hypoperfusion. Goals during the first 6 hours of resuscitation are:
Central venous pressure (CVP) 8–12 mm Hg
Mean arterial pressure (MAP) ≥65 mm Hg
Urine output ≥0.5 mL/kg/hr
Central venous (superior vena cava) or mixed venous O2 saturation 70% or 65%, respectively
In patients with elevated lactate levels, targeting resuscitation to normalize lactate (grade 2C).
Culture as clinically appropriate before antimicrobial therapy, if no significant delay (>45 min), in the start of antimicrobials.
Administer effective IV antimicrobials within the first hour of recognition of septic shock or severe sepsis. Initial empiric antimicrobial therapy usually is administrating one or more drugs that have activity against all likely pathogens (bacterial, fungal, or viral) and administered intravenously in sufficient doses to penetrate tissues in adequate concentrations to treat suspected infection.
Identify the infection source as rapidly as possible and provide interventions (e.g., remove line, deride skin, drain abscess) for source control within the first 12 hours after the diagnosis is made, if feasible.
Anticipate hemodynamic support and adjunctive therapy infection prevention:
Selective oral and skin decontamination; selective digestive decontamination as needed
Best practices in infection control, including the ventilator-associated pneumonia prevention bundle and housekeeping practices for decontamination
Add vasopressor support if fluid resuscitation does not meet the goal of MAP >65 mm Hg

4. Use the SBAR method to communicate your concerns about this patient to another nurse who will be continuing his care.
Situation: This patient arrived with a life-threatening infection. His current goals of care are fluid management and timely administration of antibiotics. His social situation and depression may be contributing to poor self-management and this admission for septicemia.
Background: His septicemia is related to new pressure ulcer and UTI. His original spinal cord injury occurred 10 years ago. This is his first hospitalization for a pressure ulcer occurrence. His previous UTIs were managed by his provider without hospitalization. He was diagnosed with depression 3 years ago but has not taken prescribed drugs to manage this condition.
Assessment: His CVP, urine output, and cognition indicate adequate tissue perfusion; continue hourly monitoring for at least 24 hours. His current problems from septicemia may be the result of his inadequate social support and copping skill pattern. His depression may be contributing to poor self-management.
Recommendation: We need to focus on resolving his septicemia with antibiotic and fluid administration. But let’s begin discharge planning now. We need to develop a multidisciplinary team to meet his care needs and establish goals of care that extend beyond the resolution of his admitting diagnosis of septicemia. We should begin with a request for the case manager or transitional care team to meet with nursing today. Let’s ask the provider for a psychiatric or psychologist consult as soon as possible.

19

p. 933, Health Promotion and Maintenance
Which statements by a client or family member about preventing stroke indicate a need for further teaching by the nurse? Select all that apply.
A. “I will adjust my aspirin drug dose depending on whether I have pain.”
B. “I have cut down on smoking to only a half-pack daily.”
C. “I need to walk at least 30 minutes most days of the week.”
D. “I need to consider salt content in the foods I eat at restaurants.”
E. “I don’t need to worry about fat calories in what I eat—my heart is fine!”

Answer: A, B, E

Rationale: Aspirin is prescribed in a fixed, low dose to prevent platelet activation and thrombus formation (ischemic stroke), not pain. Although decreasing smoking is helpful, the goal is smoking cessation. Stroke and cardiac risk are intertwined; fat calories contribute to atherosclerosis and stroke risk. Reducing salt intake and completing 30 minutes of walking daily decrease the risk for stroke.

20

p. 938, Physiological Integrity
A client begins to have severe epistaxis after completing a dose of alteplase. In order of priority, what are the nurse’s actions?
A. Obtain vital signs.
B. Assess the airway, and set up suction at bedside.
C. Draw blood for anticoagulation studies.
D. Call the health care provider.

Answer: B, A, D, C

Epistasis is a severe nosebleed, and blood can block the oropharynx. The first priority is ensuring that airway and breathing are maintained. Next determine whether adequate circulation (VS) is present. Obtaining assistance from the rapid response team or health care provider to provide timely interventions (these may include oxygen, nasal packing, or imaging tests) to prevent complications follows immediate assessment of the airway, breathing, and circulation (ABCs). Drawing blood for anticoagulation studies will guide therapy, but it is not the immediate action required to avoid a life-threatening compromise to the respiratory system.

21

p. 942, Physiological Integrity
A client with a confirmed acute ischemic stroke is comatose but breathing spontaneously. The client has an advance directive requesting limited resuscitation and is not a candidate for fibrinolytic therapy. What is the nurse’s priority action on admission?
A. Ask for palliative care consultation to assist with end-of-life decision making.
B. Consult with the speech-language pathologist about alternative strategies for communication.
C. Evaluate swallowing ability with an institution-specific, evidence-based protocol.
D. Assess vital signs and determine if the advance directives need to be communicated to the health care provider.

Answer: D

Rationale: Client values and preferences must be incorporated into high-quality care. Assessing VS will provide essential information about the urgency of obtaining an order for “Do not resuscitate” or variation provided by institutional policy. Communication with the health care provider is essential to ensure all health care team members share the client’s preference about limited resuscitation and that those wishes are reflected in the medical record. Comatose clients are unresponsive; an alternate form of communication is not feasible. Palliative care can assist with managing symptoms and may be needed in subsequent days, but the end-of-life decisions have been made and are in the advanced directive.

22

p. 953, Safe and Effective Care Environment
An alert and oriented person is admitted to the emergency department with a GCS of 10, indicating a moderate brain injury. Which assessment finding will the nurse report immediately to the health care provider?
A. Photophobia accompanied by headache
B. New onset of dizziness when lying quietly in bed
C. A brisk pupillary reaction to light
D. New difficulty in responsiveness or sudden drowsiness

Answer: D

Rationale: The change in level of consciousness is the most sensitive indicator of new or worsening brain damage and must be communicated urgently to the health care provider. Any deterioration in alertness or responsiveness in a client with new brain injury is an emergency. Although photophobia and dizziness are concerning, they are not emergencies. A brisk pupillary response is normal.

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p. 961, Physiological Integrity
A client returns from the postanesthesia care unit (PACU) after a craniotomy for removal of a left parietal lobe tumor. How will the nurse position the client after surgery?
A. Flex the client’s knees to decrease intra-abdominal pressure and cerebral hypertension.
B. Keep the client on the left side to prevent surgical site bleeding or cerebrospinal fluid leakage.
C. Elevate the client’s head to at least 30 degrees to promote cerebral venous drainage.
D. Hyperextend the client’s neck to maintain the airway and prevent aspiration regardless of supine or side-lying positioning.

Answer: C

Rationale: Elevation of the backrest allows both CSF and cerebral venous blood to drain out of the cranium. Avoid placing a client who has undergone a craniotomy on the operative side. Avoid hip and knee flexion because this increases intracranial pressure, and increased intracranial pressure from edema is common in clients after cranial surgery. Hyperextension of the neck will reduce CSF and venous outflow from the cranium.