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org

NCLEX/CGFNS REVIEW BULLETS 7

• Home modifications to reduce the risk for falls includes use of sturdy and
secure railings on all staircases and ample lighting. Bathroom safety
equipment includes the use of a shower chair, handrails in the shower and
near the toilet, and keeping a mat in the tub to prevent slipping.

• Nursing care after bone biopsy includes monitoring the site for swelling,
bleeding, and hematoma formation. The biopsy site is elevated for 24 hours
to reduce edema. The vital signs are monitored every 4 hours for 24 hours.
The client usually requires mild analgesics; more severe pain usually
indicates that complications are arising.

• A radiograph is a photographic image of a part of the body on a special film,

which is used to diagnose a wide variety of conditions. The radiograph itself is
painless; any discomfort would arise from repositioning a painful part for
filming. The nurse may want to premedicate a client who is at risk for pain.
Any radiopaque objects such as jewelry or other metal must be removed. The
client is asked to breathe in deeply, and then hold the breath while the chest
radiograph is taken. The client is not required to void before the procedure,
but may do so to enhance comfort during the procedure.

• No activity or dietary restrictions must be followed after a bone scan. The

client is encouraged to drink large amounts of water for 24 to 48 hours to
flush the radioisotope from the system. No hazards to the client or staff exist
from the minimal amount of radioactivity of the isotope. The client would not
experience nausea or flushing because contrast dye is not used for this
procedure. In addition, those sensations would likely be experienced at the
time of dye injection, not after it.

• A comminuted fracture is a complete fracture across the shaft of a bone, with

splintering of the bone into fragments. A compound fracture, also called an
open or complex fracture, is one in which the skin or mucous membrane has
been broken, and the wound extends to the depth of the fractured bone. A
simple fracture is a fracture of the bone across its entire shaft with some
possible displacement but without breaking the skin. A greenstick fracture is
an incomplete fracture, which occurs through part of the cross section of a
bone. One side of the bone is fractured, and the other side is bent.

• When a fracture is suspected, it is imperative that the area be splinted before

the client is moved. Emergency help should be called for if the client is
outside a hospital, and a physician is called if the client is hospitalized. The
nurse should remain with the client and provide realistic reassurance.

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• The procedure for casting involves washing and drying the skin and placing a
stockinette material over the area to be casted. A roll of padding is then
applied smoothly and evenly. The plaster is rolled onto the padding, and the
edges are trimmed or smooth ed as needed with a special cast knife. A
plaster cast gives off heat as it dries and may feel warm to the client. A
plaster cast can tolerate weight-bearing once it is dry, which varies from 24
to 72 hours, depending on the nature and thickness of the cast.

• The traction setup is checked routinely to assure that the ropes are in the
grooves of the pulleys; ropes are not frayed; knots are tied securely; and
weights are hanging freely from the ropes. Problems with any of these can
interfere with maintenance of proper traction. If any problems are noted, they
should be fixed immediately.

• Buck’s extension traction is a type of skin traction often applied after hip
fracture before the fracture is reduced in surgery. It reduces muscle spasms
and helps to immobilize the fracture. It does not completely immobilize the
fracture. It does not lengthen the leg to prevent blood vessel damage. It also
does not allow bony healing to begin.

• Purulent drainage can indicate infection at the pin insertion site, and the
nurse would reassess the client’s temperature as another indication of the
presence of infection. A small amount of serous oozing is expected at pin-
insertion sites. Serosanguineous drainage may be present in small amounts
initially, but does not indicate infection. Sanguineous drainage also is of
concern and should be brought to the attention of the physician.

• Self-Care Deficit applies when the client is unable to perform activities of

daily living (ADLs) independently. A major defining characteristic of Deficient
Diversional Activity is expression of boredom by the client. Activity
Intolerance applies when the client has a decreased tolerance for activity or
exercise, which is reflected by excessive fatigue or change in vital signs with
activity. Impaired Physical Mobility is present when the client has difficulty
with coordination, range of motion, or muscle strength.

• Buck’s extension traction is a type of skin traction. The nurse should inspect
the skin of the limb in traction at least once every 8 hours for irritation or
inflammation.

• Exercise is indicated within therapeutic limits for the client in skeletal traction
to maintain muscle strength and ROM. The client should not, however, do
active ROM to the involved joints, because it would disrupt the pull of the
traction force. The client may pull up on the trapeze, perform active ROM
with uninvolved joints, and do isometric muscle-setting exercises (such as

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 quadriceps- and gluteal-setting exercises). The client may also flex and
extend the feet.

• Signs and symptoms of infection under a casted area include odor or purulent
drainage from the cast or the presence of “hot spots,” which are areas of the
cast that are warmer than others. The physician should be notified if any of
these occur. Signs of impaired arterial circulation in the distal limb include
coolness and pallor of the skin and diminished arterial pulse. Edema indicates
impaired venous return in the extremity.

• A casted extremity is elevated continuously for the first 24 to 48 hours to

minimize swelling and to promote venous drainage.

• Standard management of the client with deep vein thrombosis includes bed
rest for a period as prescribed; limb elevation; relief of discomfort with warm
moist heat and analgesics as needed; anticoagulant therapy; and monitoring
for signs of pulmonary embolism. Ambulation is contraindicated, because the
tail of the thrombus could dislodge and travel to the lungs as a pulmonary
embolus. This is most likely to occur in the first 24 to 48 hours after clot
formation.

• Clients with chronic venous insufficiency are advised to avoid crossing the
legs, sitting in chairs where the feet do not touch the floor, wearing garters or
sources of pressure above the legs (such as girdles), and to avoid prolonged
standing or sitting. The client should wear elastic hose for 6 to 8 weeks, and
perhaps for life. The client should sleep with the foot of the bed elevated to
promote venous return during sleep.

• Successful resolution of the deep vein thrombosis is marked by the absence

of original symptoms used to diagnose the problem (unilateral leg warmth,
redness, edema, tenderness, enlarged calf).

• Legal blindness implies that the person cannot perform work that requires
visual ability. The person who is legally blind usually retains some perception
of light and movement. Total blindness means the absence of all light
perception. Low vision is a term that is used to refer to a legally blind person
or persons with severe vision impairment who still have some visual ability.

• Tonometry is an effective screen for the early detection of glaucoma.

The normal intraocular pressure is 12 to 22 mm Hg. An intraocular
pressure of 20 mm Hg is a normal finding.

• As the placenta separates, it settles downward into the lower uterine

segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood
appears. Placenta previa is the sudden onset of painless uterine bleeding in
the latter half of pregnancy. Abruptio placentae is characterized by

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 abdominal pain and vaginal bleeding. Uterine atony relates to a uterus that is
not firmly contracted.

• The fourth stage of labor is the stage of physical recovery for the
mother and infant. It lasts from the delivery of the placenta through
the first 1 to 4 hours after birth. A potential complication after
delivery is hemorrhage. The most significant source of bleeding is
the site where the placenta was implanted. It is critical that the
uterus remain contracted and that the nurse monitors vaginal blood
flow every 15 minutes for the first 1 to 2 hours.

• Vaginal bleeding in a pregnant client most often is caused by placenta previa

or a placental abruption. Uterine tenderness accompanies placental
abruption, especially with a central abruption and trapped blood behind the
placenta. The abdomen will feel hard and boardlike on palpation as the blood
penetrates the myometrium and causes uterine irritability. A sustained
tetanic contraction can occur if the client is in labor and the uterine muscle
cannot relax. Placental abruption is characterized by the presence of uterine
pain and tenderness.

• It is not advisable to bathe a newborn or infant after a feeding because

handling may cause regurgitation. Because bathing is thought to be relaxing
to the newborn, before feeding may be the best time.

• Because the placenta is implanted in the lower uterine segment that does not
contain the same intertwining musculature as the fundus of the uterus, this
site is more prone to bleeding. The nurse then has to assess the client
carefully for signs of postpartum hemorrhage.

• DIC is a state of diffuse clotting in which clotting factors are consumed. This
leads to widespread bleeding. The presence of petechiae, oozing from
injection sites, and hematuria is indicative of the presence of DIC. Platelets
are decreased because they are consumed by the process; coagulation
studies show no clot formation (and are thus prolonged); and fibrin plugs may
clog the microvasculature diffusely, rather than in an isolated area.

• With a client in shock, the goal is to increase perfusion to the placenta. The
initial nursing action would be to turn the mother on her side. This would
increase blood flow to the placenta by relieving pressure from the gravid
uterus on the great vessels.

• Chest tube drainage in the first 24 hours after thoracic surgery may total 500
to 1000 mL. Between 100 and 300 mL of drainage may accumulate during
the first 2 hours.

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• After supratentorial surgery, the head of the bed is kept at a 30- to 45-degree
angle. The head and neck should not be angled either anteriorly or laterally,
but rather should be kept in a neutral (midline) position. This will promote
venous return through the jugular veins, which will help prevent increases in
intracranial pressure.

• One of the complications of cranial surgery is meningitis. Signs of meningeal

irritation include nuchal rigidity, which is characterized by a stiff neck and
soreness, and is especially noticeable when the neck is flexed. Pupils that are
equal and reactive at 4 mm in size are normal. Mild headache relieved by
codeine sulfate is an expected finding at this time. Disorientation to date is
not of most concern when the client has been hospitalized for cranial surgery.

• The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value
indicates dehydration; a lower value indicates overhydration. After
craniotomy, the goal is to keep the serum osmolality on the high side of
normal, which would help to control cerebral edema. Because a serum
osmolality of 280 mOsm/kg H2O is low, the client is overhydrated and is at
risk for cerebral edema. The nurse should report this finding. Each of the
other options represents fluid balance measurements that are normal or
expected findings.

• Codeine sulfate is the narcotic analgesic of choice for clients after

craniotomy. It is often combined with a non-narcotic analgesic, such as
acetaminophen (Tylenol) for added effect. It does not alter the respiratory
rate or mask neurological signs, as other narcotics do. Side effects of codeine
sulfate include gastrointestinal upset and constipation. The medication can
lead to physical and psychological dependence with prolonged use.

• The postcraniotomy client may find that loud noises, such as a loud
television, are irritating. It is helpful to the client if the family keeps noise
within normal ranges or softer. Seizures are a potential complication that can
occur for up to 1 year after surgery. For this reason, the client must diligently
take anticonvulsant medications. The client and family are encouraged to
keep track of doses administered. The family should learn seizure precautions
and accompany the client while ambulating if dizziness occurs. The suture
line is kept dry until sutures are removed to prevent infection.

• Dexamethasone is an adrenocorticosteroid administered after craniotomy to

control cerebral edema. It is given by IV push, and single doses are
administered over a 1-minute period. Dexamethasone doses are changed to
the oral route after 24 to 72 hours and are tapered in dose until discontinued.

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• Sensation is tested by using sharp and dull objects and having the client
discriminate between them. The nurse starts at the shoulder level and works
downward in a systematic manner to test sensation.

• Crutchfield tongs are a type of skeletal traction, which have weights attached
to the tongs. The weights exert pulling pressure on the longitudinal axis of
the cervical spine and gradually realign the spine. The nurse and other
personnel must not remove the weights to administer care. The client with
Crutchfield tongs is placed on a Stryker frame or Roto-rest bed. The nurse
ensures that weights hang freely, and the amount of weight matches the
current order. The nurse also inspects the integrity and position of the ropes
and pulleys.

• The placenta is implanted low in the uterus in placenta previa, and a vaginal
examination could cause the disruption of the placenta and initiate severe
hemorrhage.

• Adjusting to paralysis is difficult both physically and psychosocially for the

client and family. The nurse recognizes that the client goes through the
grieving process in adjusting to the loss and may move back and forth among
the stages of grief. The nurse acknowledges the client’s feelings while
continuing to meet the client’s physical needs and encouraging
independence.

• The client with a Halo vest may not drive because the device impairs the
range of vision. The Halo device alters balance and can cause fatigue
because of its weight. The client should clean the skin daily under the vest to
protect the skin from ulceration and should use powder or lotions sparingly or
not at all. The client should use straws for drinking and have food cut into
small pieces to facilitate chewing.

• After SCI, the client can develop paralytic ileus, which is characterized by the
absence of bowel sounds and abdominal distention. Development of a stress
ulcer can be detected by Hematest positive NGT drainage or stool. This
indicates development of an important complication and should be reported
immediately. A single episode of diarrhea is not a cause for alarm, although
the nurse should continue to watch for a pattern.

• The client who has had a SCI experiences significant losses in most areas of
daily living. It is important for the nurse to understand that the client may be
looking for new areas of control as a result of feelings of helplessness.

• The client should use a mirror to inspect the skin twice a day (morning and
evening) to assess for redness, edema, and breakdown. To prevent pressure
ulcers from developing, the paraplegic client should shift weight in the

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 wheelchair every 2 hours and use a pressure-relief pad. While the client is in
bed, the bottom sheet should be free of wrinkles and wetness.

• ROM to the hands is helpful to prevent contractures but does not actively
strengthen muscle groups needed for self-mobilization with paraplegia. Other
activities that are more effective in moving larger muscle groups include
push-ups from a prone position, sit-ups from a sitting position, extending the
arms while holding weights, and squeezing rubber balls or crumpling
newspaper.

• The client with SCI is at risk for autonomic dysreflexia if the injury is
above the level of T7. It is characterized by severe, throbbing
headache, flushing of the face and neck, bradycardia, and sudden
severe hypertension. Other signs include nasal stuffiness, blurred
vision, nausea, and sweating. It is a life-threatening syndrome
triggered by a noxious stimulus below the level of the injury. It is
very important that the nurse recognize this complication so that
quick action may be taken to remove the noxious stimulus.

• Episodes of autonomic dysreflexia can be caused by stimulation of

the skin from tactile, thermal, or painful stimuli. The nurse
administers care to minimize risk in these areas. Linens are kept
free of wrinkles, and bed clothing is kept loose around the client to
prevent mechanical irritation of the skin. The most frequent cause of
autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours, and a Foley
catheter should be checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are other causes, so
maintaining bowel regularity is important. A bowel movement every
5 days is too infrequent.

• Key nursing actions are (in order of priority) to sit the client up in bed,
remove the noxious stimulus, and bring the blood pressure under control with
antihypertensive medication per protocol. The nurse also can clearly label the
client’s chart, identifying the risk for autonomic dysreflexia. The client and
family should be taught to recognize, and later manage, the signs and
symptoms of this syndrome.

• The client with Parkinson’s disease experiences bradykinesia and can be

taught to rock back and forth to initiate movement. The client should avoid
sitting in soft, deep chairs, because they are difficult to get up from. The
client should buy clothes with Velcro fasteners and slide locking buckles to
support independence in getting dressed. The client should exercise in the
morning when energy levels are highest.

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• Trigeminal neuralgia is characterized by spasms of pain that start suddenly
and last for seconds to minutes. The pain is often characterized as stabbing
or is similar to an electric shock. It is accompanied by spasms of facial
muscles, which cause twitching of parts of the face or mouth, or closure of
the eye.

• The paroxysms of pain that accompany this neuralgia are triggered by

stimulation of the terminal branches of the trigeminal nerve. Symptoms can
be triggered by pressure from washing the face, brushing the teeth, shaving,
eating, and drinking. Symptoms also can be triggered by thermal stimuli such
as a draft of cold air.

• The postoperative care of the client having microvascular decompression of

the trigeminal nerve is the same as that for the client undergoing craniotomy.
This client requires hourly neurological assessment, as well as monitoring of
cardiovascular and respiratory status. Suctioning is done very cautiously and
only when necessary to avoid increasing the intracranial pressure (ICP).

• Bell’s palsy is a one-sided facial paralysis from compression of the facial

nerve (CN VII). Facial droop occurs from paralysis of the facial muscles,
increased lacrimation, painful sensations in the eye, face, or behind the ear,
and speech or chewing difficulties.

• Clients with Bell’s palsy should be reassured that they have not experienced
a stroke and that symptoms often disappear spontaneously in 3 to 5 weeks.
The client is given supportive treatment for symptoms.

• Prevention of muscle atrophy with Bell’s palsy is accomplished with the use
of facial massage, facial exercises, and electrical stimulation of the nerves.
Local application of heat to the face may improve blood flow and provide
comfort. Exposure to cold or drafts is avoided.

• Guillain-Barré syndrome is a clinical syndrome of unknown origin

that involves cranial and peripheral nerves. Many clients report a
history of respiratory or GI infection in the 1 to 4 weeks before the
onset of neurological deficits. Occasionally, it has been triggered by
vaccination or surgery.

• Guillain-Barré syndrome is a clinical syndrome of unknown origin that

involves cranial and peripheral nerves. Many clients report a history of
respiratory or GI infection in the 1 to 4 weeks before the onset of neurological
deficits. Occasionally, it has been triggered by vaccination or surgery.

• To manage constipation effectively, the client should take in a high-fiber diet,

bulk formers, and stool softeners. A fluid intake of 2000 mL per day is
recommended. The client should initiate the bowel program on an every-

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 other-day basis. This should be done approximately 45 minutes after the
largest meal of the day, to use the gastrocolic reflex. A glycerin suppository,
bisacodyl suppository, or digital stimulation may be used to initiate the
process. Laxatives and enemas should be avoided whenever possible
because they lead to dependence.

• Venography is similar to arteriography, except it evaluates the

venous system. A radiopaque dye is injected into selected veins to
evaluate patency and blood-flow characteristics. Allergies to
shellfish or iodine must be noted, because this could mean that the
client would be allergic to the contrast dye. The client signs an
informed consent because it is an invasive procedure. Peripheral
pulses are assessed so comparisons can be made after the
procedure. The client is usually given clear liquids for 3 to 4 hours
before the procedure to help with dye excretion afterward.

• A blackened appearance on an ulcerated area indicates necrosis and

developing gangrene, which must be reported to the physician. Pressure
dressings or dry sterile dressings will not help the serious circulatory problem
presented here. Turning up the heat in the room may be partially helpful, but
again will not address the concern addressed in the question.

• Raynaud’s phenomenon is a condition in which the small arteries and

arterioles constrict in response to various stimuli. Episodes are characterized
by pallor, cold, numbness, and possible cyanosis, followed by erythema,
tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine,
caffeine, stress, and trauma, or jarring movements of the fingertips.

• Raynaud’s phenomenon is a condition in which the small arteries

and arterioles constrict in response to various stimuli. Raynaud’s
phenomenon is frequently seen associated with collagen disorders
such as rheumatoid arthritis, scleroderma, and lupus erythematosus.
Other factors that may contribute to the disorder include
occupationally related trauma or pressure to the fingertips such as
seen in typists, pianists, use of hand held vibrating tools, and
exposure to heavy metal.

• Intermittent claudication is a classic symptom of peripheral vascular disease,

also known by other names, including peripheral arterial disease and chronic
arterial insufficiency. It is described as a cramplike pain that occurs with
exercise and is relieved by rest.

• The classic manifestations of peripheral arterial disease include color changes

(pallor, rubor, cyanosis), temperature changes, and trophic changes in the
affected extremity. The pedal pulse diminishes and becomes absent as the

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 disease progresses. Progression of pain from intermittent claudication to rest
pain indicates a severe degree of occlusion and a critical state of ischemia.

• Causes of autonomic dysreflexia include bladder distention, bowel distention

from constipation or fecal impaction, and stimulation of the skin from pain,
pressure, or changes in temperature. The client and family should learn the
triggering factors, methods of preventing them from occurring, and how to
manage an episode.

• Signs and symptoms of spinal shock include loss of skeletal muscle

movement, loss of bowel and bladder tone, and loss of autonomic
reflexes below the level of the injury. Sexual function also is lost.
The limbs have a flaccid paralysis, and bowel and bladder retention
occurs. The client in spinal shock has special needs, and it is
important for the nurse to recognize this condition.

• Subarachnoid precautions (or aneurysm precautions) are intended to

minimize environmental stimuli, which could increase intracranial pressure
(ICP) and trigger bleeding or rupture of the aneurysm.

• Kegel exercises are extremely important to strengthen the muscle tone of the
perineal area. Postpartum exercises can begin soon after birth. The initial
exercises should be simple, with progression to increasingly strenuous
exercises. Postpartum exercises will not result in stress urinary incontinence.

• The most accurate method for determining the amount of lochial flow is to
weigh the perineal pads before and after use. Once these two weights are
noted, the amount of lochial flow can be accurately determined. Each gram
increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain
an accurate estimate of lochial flow, the time factor must be incorporated
into the analysis.

• One of the earliest indicators of successful adaptation of the

newborn infant is the Apgar score. Scoring ranges from 0 to 10. It
uses five criteria to measure the infant’s adaptation. Heart rate:
absent, 0; less than 100, 1; greater than 100, 2. Respiratory effort:
absent, 0; slow or irregular weak cry, 1; good, crying lustily, 2.
Muscle tone: limp or hypotonic, 0; some extremity flexion, 1; active,
moving, and well flexed, 2. Irritability or reflexes (measured by bulb
suctioning): no response, 0; grimace, 1; cough, sneeze, or vigorous
cry, 2. Color: cyanotic or pale, 0; acrocyanotic, cyanosis of
extremities, 1; pink, 2.

• The normal respiratory rate for a newborn infant is 30 to 60 breaths/minute.

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• The anterior fontanel is diamond shaped and located on the top of
the head. It should be flat and soft and may range in size from
almost nonexistent to 4 to 5 cm across. It normally closes by age 18
to 24 months.

• A caput succedaneum indicates swelling of the soft tissues of the

head and scalp that may extend across suture lines. It is most
pronounced after a long labor, is evident within 24 hours after birth,
and resolves within a few days.

• cephalhematoma is an edema resulting from bleeding below the periosteum

of the cranium.

• Gastroschisis is an abdominal wall defect. Embryonal weakness in

the abdominal wall causes herniation of the gut on one side of the
umbilical cord during early development. The viscera are located
outside the abdominal cavity and are not covered with a sac.

• Omphalocele is a defect in which the vicera is outside the abdominal

cavity but inside a translucent sac covered with peritoneum and
amniotic membrane

• Imperforate anus (anal atresia, anal agenesis) is the incomplete

development or absence of the anus in its normal position in the
perineum.

• Esophageal atresia and tracheoesophageal fistula (TEF) are congenital

malformations in which the esophagus terminates before it reaches the
stomach and/or a fistula is present that forms an unnatural connection with
the trachea.

• Congenital diaphragmatic hernia is an herniation of abdominal

contents through an opening of the diaphram.

• Clinical manifestations associated with CDH include diminished or

absent breath sounds on the affected side; bowel sounds heard over
the chest; cardiac sounds heard on the right side of the chest;
respiratory distress developing soon after birth including dyspnea,
cyanosis, nasal flaring, tachypnea, retractions; and a scaphoid
abdomen.

• clinical manifestation of esophageal atresia and tracheoesophageal fistula is

excessive oral secretions.

• clinical manifestation of gastroesophageal reflux is hiccupping and splitting

up after a meal.

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• characteristic of a hiatal hernia includes coughing, wheezing and short
periods of apnea.

• Morning sickness is common during the first trimester of pregnancy and is

associated with increased levels of human chorionic gonadotropin (hCG) and
changes in carbohydrate metabolism. It most often occurs on arising,
although a few women experience it throughout the day. Self-care measures
include eating a dry cracker or toast before getting out of bed, eating small
frequent meals, avoiding fatty or spicy foods, and rising slowly from a lying or
sitting position to avoid orthostatic hypotension.

• Urinary frequency is present in the first trimester and late in the third
trimester because of the pressure placed on the bladder by the enlarged
uterus. Self-care measures for urinary frequency include emptying the
bladder frequently (every 2 hours) and continuing to drink at least 2000 mL
of fluid a day.

• Ankle edema is a common occurrence and is caused by decreased venous

return from the feet because of gravity. It is a minor discomfort as long as
hypertension and proteinuria are not present. Self-care measures for ankle
edema include elevating the feet at hip level during the day, taking frequent
rest periods, wearing supportive stockings or hose, and avoiding standing in
one position or place for long periods.

• Heartburn is associated with regurgitation of gastric acid contents into the

esophagus. Self-care for heartburn includes eating small frequent meals,
avoiding fatty or spicy foods, remaining upright for 30 minutes after eating,
and drinking approximately 2000 mL of fluid per day.

• To assess and evaluate the presence of pitting edema, the nurse

uncovers the woman’s lower leg, presses the fingertips of the index
and middle finger against the shin, and holds the pressure for 2 to 3
seconds.

• When evaluating the presence of pitting edema, the nurse presses

the fingertips of the index and middle fingers against the shin and
holds pressure for 2 to 3 seconds. An indentation of approximately 1
inch deep would be indicative of 4+ edema. A slight indentation
would indicate 1+ edema. An indentation of approximately ¼ inch
deep indicates 2+ edema. An indentation of approximately 1/2 inch
deep indicates 3+ edema.

• When evaluating the deep tendon reflex, the normal response should be an
extension and thrusting of the foot upward. A 1+ response indicates a

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 diminished response; 2+ indicates normal; 3+ indicates increased, brisker
than average; and 4+ indicates a very brisk hyperactive response.

• To detect the presence of clonus, the nurse places one hand under
the women’s knee and bends the knee slightly. The nurse then
places the other hand on the ball of the foot, encourages the women
to relax her leg and foot, and sharply dorsiflexes the foot. Clonus is
present if the foot jerks or taps against the nurse’s hand.

• Discomfort and pain associated with true labor contractions typically begins
in the lower abdomen and back and then radiates over the entire abdomen.

• The placenta provides an exchange of nutrients and waste products between

the mother and fetus. The amniotic fluid surrounds, cushions, and protects
the fetus and maintains the body temperature of the fetus. Nutrients,
medications, antibodies, and viruses can pass through the placenta.

• The FHR can first be heard with a fetoscope at 18 to 20 weeks of gestation. If

a Doppler ultrasound device is used, the FHR can be detected as early as 10
weeks of gestation.

• The FHR should be approximately 110 to 160 beats/minute throughout

pregnancy. Because the FHR is elevated from the normal range, the nurse
would contact with the physician.

• An infant born to an HIV-positive mother is at risk for developing the disease.

Characteristically, the newborn is asymptomatic at birth, but signs and
symptoms usually become obvious during the first year of life.

• Low or oddly placed ears are associated with a variety of congenital defects
and should be reported immediately. Although the findings would be
documented, the most appropriate action would be to notify the physician.

• Pelvic-tilt exercises decrease strain to muscles of the abdomen and lower

back caused by the added weight of the abdomen and the shift in the center
of gravity. An abdominal support should only be worn if recommended by the
physician. Relaxing abdominal muscles will add to the problem. Wearing
high-heeled shoes will add to the strain on the muscles and will exaggerate
the shift in the center of gravity.

• Rho(D) immune globulin IGIM (RhoGAM) is administered at 28 weeks of

gestation to a woman as described, with a second injection within 72 hours of
delivery. This prevents sensitization, which could jeopardize a future
pregnancy. For subsequent pregnancies or abortions, the injections must be
repeated, because immunity is passive.

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• Folic acid is needed during pregnancy for healthy cell growth and repair. A
pregnant woman should have at least four servings of folic acid–rich foods
per day.

• A reactive nonstress test (normal/negative) indicates a healthy

fetus. It is described as two or more fetal heart rate (FHR)
accelerations of at least 15 beats/minute, lasting at least 15 seconds
from the beginning of the acceleration to the end, in association
with fetal movement, and during a 20-minute period. A nonreactive
nonstress test (abnormal) is described as no accelerations or
accelerations of less than 15 beats/minute or lasting less than 15
seconds for a 40-minute observation. An unsatisfactory test cannot
be interpreted because of the poor quality of the FHR.

• A contraction stress test assesses placental oxygenation and function,

determines fetal ability to tolerate labor, determines fetal well-being, and is
performed if the nonstress test is abnormal. The fetus is exposed to the
stressor of contractions to assess the adequacy of placental perfusion under
simulated labor conditions. An external fetal monitor is applied to the mother,
and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to
contract either by the administration of a dilute dose of oxytocin (Pitocin) or
by having the mother use nipple stimulation until three palpable contractions
with a duration of 40 seconds or more in a 10-minute period have been
achieved. Frequent maternal blood pressure readings are done, and the
client is monitored closely while increasing doses of oxytocin are given.

• Slowing or stopping of fetal movement may be an indication that the fetus

needs some attention and evaluation. Women are advised to count fetal
movements for 30 to 60 minutes, 3 times a day (usually after meals when the
fetus is more active). The client lies down on the left side during the
procedure because it provides optimal circulation to the uterus-placenta-fetus
unit. Most women count four movements in 1 hour. The midwife or health
care provider is notified if 10 movements are not felt in a 12-hour period.

• HIV is transmitted by intimate sexual contact and the exchange of body

fluids, exposure to infected blood, and transmission from an infected woman
to her fetus. Women in the high-risk category for HIV infection include those
with persistent and recurrent sexually transmitted diseases or a history of
multiple sexual partners, and those who have used IV drugs.

• Infected house cats transmit toxoplasmosis through feces. Handling litter

boxes can transmit the disease to the maternity client. Hands should be
washed throughout the day when items that could be contaminated are
handled.

14
• An intervention to prevent sickle cell crisis during labor includes
administering oxygen. During the labor process, the client is at high risk for
being unable to meet the oxygen demands of labor and is at high risk for
sickle cell crisis.

• To further to assess and plan for the newborn’s care, the newborn’s blood
type and direct Coombs' must be known. Umbilical cord blood is taken at the
time of delivery to determine blood type, Rh factor, and antibody titer (direct
Coombs' test) of the newborn. If the newborn’s blood type is Rh negative, or
if the newborn’s blood type is Rh positive with a negative direct Coombs' test,
then no concern is needed for Rh incompatibility. If the newborn’s blood type
is Rh positive and the direct Coombs' is positive, then Rh incompatibility
exists.

• The initial nursing action when a client has a seizure (eclampsia) is to

maintain an open airway.

• An empty bladder contributes to a woman’s comfort during the examination.

Drinking water to fill the bladder and warming sonogram gel may be
performed before a sonogram but are not applicable to performing Leopold
maneuvers. Often the Leopold maneuvers are performed to aid the examiner
in locating the fetal heart tones.

• The goal of labor augmentation is to achieve three good-quality contractions

(appropriate intensity and duration) in a 10-minute period. The uterus should
return to resting tone between contractions with no evidence of fetal distress.
Acute hypoxia is a common cause of fetal tachycardia. The dosage of
oxytocin should be decreased in the presence of fetal tachycardia from
excessive uterine activity. The nurse should also assure that the uterus
maintains an adequate resting tone between contractions.

• Accelerations are transient increases in the fetal heart rate (FHR).

Accelerations are normally caused by fetal movement or often accompany
contractions. Accelerations are thought to be a sign of fetal well-being and
adequate oxygen reserve.

• Variable decelerations, present on a fetal heart monitor, suggest cord

compression. Early decelerations result from pressure on the fetal head
during a contraction. Late decelerations are an ominous pattern in labor
because they suggest uteroplacental insufficiency during a contraction.
Short-term variability refers to the difference between successive heartbeats,
identifying that the natural pacemaker activity of the fetal heart is working
properly.

15
• Late decelerations are due to uteroplacental insufficiency as the result of
decreased blood flow and oxygen transfer to the fetus during uterine
contractions. This causes hypoxemia; therefore oxygen is necessary,

• Effleurage is a specific type of cutaneous stimulation involving light stroking

of the abdomen and is used before transition to promote relaxation and
relieve mild to moderate pain.

• Relaxation techniques include specific relaxation exercises and

conditioned responses, such as distraction from the discomfort of
labor. The woman is an active participant in the use of these
techniques, which focus in relaxing uninvolved muscles while the
uterus contracts.

• When the membranes rupture in the birth setting, the nurse immediately
assesses the FHR to detect changes associated with prolapse or compression
of the umbilical cord.

• Large quantities of alcohol have been associated with an increased risk of

liver cancer. However, according to the client’s statement, the client
understood that no alcohol may be consumed. Thus the client requires
reinforcement that alcohol is the substance associated with liver cancer;
however, clarification is needed that it is an excessive intake that is
associated with liver cancer.

• Decreased aldosterone secretion results in a fluid volume deficit.

Clients are encouraged to maintain an oral intake of 3000 mL/day to
avoid dehydration. Clients require a high sodium diet to replace
losses. Snacks between meals are encouraged, to prevent
hypoglycemia. Clients with Addison’s disease require hormone-
replacement therapy with corticosteroids.

• Addisonian crisis is a serious, life-threatening response to acute adrenal

insufficiency that is most commonly precipitated by a major stressor. The
client with addisonian crisis may have any of the signs or symptoms of
Addison’s disease, but the primary problems are sudden profound weakness;
severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia;
peripheral vascular collapse; coma; and renal failure.

• Typical discharge instructions after AICD implantation include reporting to the

physician symptoms indicating dysrhythmias, such as fainting, blackouts,
rapid pulse, weakness, or nausea. The physician may want to be called each
time the device discharges. At a minimum, the client should keep a log
recording the date, time, symptoms, and activity before the shock, the
number of shocks delivered, and how the client felt afterward. The physician

16
 will use this information in managing the ongoing medication regimen. The
community emergency medical system should be notified about the device,
so they are prepared if they are called to the home. Contingency plans for
health care should be made before travel. The family also should become
trained in cardiopulmonary resuscitation (CPR).

• No special restrictions are imposed after a bone scan. The client is

encouraged to drink large amounts of water for 24 to 48 hours to flush the
radioisotope from the system. No hazards to the client or staff exist from the
minimal amount of radioactivity of the isotope.

• A hepatitis A vaccine is available for administration to protect against the

infection. In addition, a standard immunoglobulin for passive immunization
can be given prophylactically or after exposure. The immunoglobulin for
passive immunization provides protection from infection for approximately 2
months. Hepatitis A is transmitted via the fecal-oral route

• Outcomes indicating that peritonitis has resolved include an afebrile

condition, absence of rebound tenderness, clear appearance of dialysate,
absence of bacteria in dialysate, normal WBC count, and no redness or
swelling at the catheter site.

• Medical management of hyperparathyroidism includes increasing urinary

calcium excretion with diuretics.

• Clients with hypoparathyroidism experience symptoms related to

hypocalcemia ranging from mild paresthesias due to the tetany and possible
seizures. Treatment for the disorder involves correction of the hypocalcemia
and vitamin D deficiency with pharmacological intervention such as calcium
chloride, vitamin D, and calcitriol (Rocaltrol). Nurses should encourage
compliance with the prescription regimen as well as teach the client that
treatment for this disorder is lifelong. In addition to pharmacological
compliance, the client should maintain certain dietary guidelines (high
calcium, low phosphorus) if the disease is to be controlled.

• PTU is administered to clients in thyroid storm to block thyroid

hormone synthesis of T3 and T4. Thyroid antibodies indicate
whether an autoimmune disease is causing the client's symptoms. A
thyroid scan provides information about whether excessive or
diminished activity is present in the gland but provides no
information about the degree of hormone synthesis. The TSH
stimulation test differentiates primary from secondary
hypothyroidism.

17
• The client learns to void after creation of a neobladder by relaxing the
external sphincter while increasing the intra-abdominal pressure (Valsalva
maneuver). If the client cannot perform this procedure, then the client must
learn to do intermittent catheterization of the neobladder.

• In the absence of documented heart disease, the desired goal is to

have a total cholesterol less than 200 mg/dL, low LDL levels of less
than 130 mg/dL, and high HDL levels greater than 50 mg/dL. In the
absence of documented heart disease or significant risk factors, the
values identified in the question place the client at a low risk for
heart disease.

• The oropharynx (mouth) should be suctioned last to prevent introducing oral

bacteria into the lung field. Allowing at least 30-second intervals between
suctioning times will allow the client to equilibrate. Pressure beyond 120 mm
Hg will damage the mucous membranes. The suction catheter should not be
left in the trachea for more than 15 seconds, or the client will experience
hypoxia.

• MRI is a test that involves an external magnetic field to visualize soft tissues.
Because of the magnetic field, this test is contraindicated in clients with
pacemakers because it can reprogram the pacemaker.

• Although esophageal varices are caused by portal pressure, rupture of the

varices may be caused by increased intrathoracic pressure such as coughing
and straining. This pressure may occur during heavy weight-lifting.

• The term nephrotic syndrome refers to a kidney disorder characterized by

proteinuria, hypoalbuminemia, and edema. The child experiences fatigue,
anorexia, increased weight, abdominal pain, and a normal blood pressure.

• Nicardipine hydrochloride (Cardene) is a calcium channel blocker that is used

to treat chronic stable angina or primary hypertension. Before administering
the medication, the nurse would check the client’s blood pressure and pulse
rate.

• Epstein-Barr virus is transmitted by contact with infectious saliva,

close intimate contact with an infectious individual, or contact with
infected blood. The infectious period is unknown. Commonly, the
virus is shed before clinical onset of the disease until 6 months or
longer after recovery.

• Early signs of lithium toxicity include vomiting, diarrhea, lethargy, and muscle
twitching. Moderate toxicity results in ataxia, giddiness, tinnitus, blurred
vision, clonic movements, and severe hypotension. Acute toxicity is
characterized by seizures, oliguria, circulatory failure, and death.

18
• Poor nutrition during pregnancy can negatively influence fetal growth and
development. Although pregnancy poses some nutritional risk for the mother,
not all clients are at high risk. Calcium is critical during the third trimester,
but must be increased from the onset of pregnancy. Intake of dietary iron is
usually insufficient for the majority of pregnant women, and iron supplements
are routinely encouraged.

• One of the earliest indicators of successful adaptation of the newborn infant

is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates
that the infant is adjusting well to extrauterine life. A score of 5 to 7 often
indicates an infant who requires some resuscitative intervention. Scores of
less than 5 indicate infants who are having difficulty adjusting to extrauterine
life and require vigorous resuscitation.

• Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The

increased tone of this muscle is beneficial during pregnancy and afterward.

• Hemorrhoids are varicosities and are likely to be precipitated during

pregnancy by the pressure of the growing fetus inside the abdominal cavity.
Standing aggravates the problem. Dietary factors, such as fluids and bulk,
and manual reduction are measures that should be included in the plan of
care. Hormonal changes are not a factor in the development of hemorrhoids
during pregnancy.

• Oxygen is administered continuously during labor to the client with sickle cell
anemia to provide adequate oxygenation and prevent sickling.

• HELLP is a laboratory diagnosis for a variant of severe preeclampsia and is

characterized by hemolysis (H), elevated liver enzymes (EL), and low
platelets (LP). One of the signs of HELLP syndrome is a decrease in the
platelet count.

• When performing fundal massage, one hand is placed just above the
symphysis pubis to support the lower uterine segment, while the fundus is
gently but firmly massaged in a circular motion. Pushing on an uncontracted
uterus could invert the uterus and cause massive hemorrhage.

• Symptoms of infection are moistness, oozing, discharge, and a reddened

base around the cord. If symptoms of infection occur, the mother should be
instructed to notify a health care provider because antibiotics may be
needed. If these symptoms occur, antibiotics are necessary.

• In term infants, jaundice first appears after 24 hours and disappears by the
end of day 7. Jaundice is first noticed in the head, especially the sclera and
mucous membranes. The newborn infant has a high rate of bilirubin

19
 production. The reabsorption of bilirubin from the neonatal small intestine is
considerable.

• Criteria for early discharge in the newborn infant include no evidence of

significant jaundice within the first 24 hours after birth. The infant should
have urinated and passed at least one stool, completed at least two
successful feedings, and have normal vital signs for at least 12 hours. These
criteria may vary depending on agency policy.

• If the newborn infant is apneic or has gasping respirations after

stimulation, or if the heart rate is below 90 beats/minute, positive-
pressure ventilation by bag and mask can be given. The ventilation
bag used for neonatal resuscitation should have a pressure gauge.
Ventilations should be given at a rate of 40 to 60 breaths/minute at
pressures of 15 to 20 cm H2O. An initial pressure of 30 to 40 cm H2O
may be necessary to inflate collapsed alveoli.

• After the placenta separates, it can usually be delivered if the mother bears
down. The cord may be gently pulled to assist in the delivery of the placenta.
Excess traction on the cord may cause it to break, making the placenta
harder to deliver.

• Complete uterine rupture results in massive blood loss; however, external

bleeding may not be noted because most of the blood is lost into the
peritoneal cavity. Signs of shock, as evidenced by a decrease in blood
pressure, tachycardia, tachypnea, pallor, cool and clammy skin, anxiety, and
pain, develop quickly. Cessation of uterine contractions occurs.

• The nurse should report the time of the last food intake to the physician.
General anesthesia may be used for an emergency cesarean delivery. Gastric
contents are very acidic and can produce chemical pneumonitis if aspirated.

• Situational Low Self-Esteem represents temporary negative feelings about

self in response to an event.

• Ineffective Coping implies that the person is unable to manage stressors

adequately.

• Dysfunctional Grieving implies prolonged unresolved grief leading to

detrimental activities.

• Deficient Knowledge indicates a lack of information or psychomotor skill

concerning a condition or treatment.

• Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour.

20
• Abnormal labor patterns are assessed according to the nature of the cervical
dilation and fetal descent. Progressive changes in the cervix are a reassuring
pattern in labor

• After a precipitate delivery, the mother may need help to process what has
happened and time to assimilate it all. The mother may be exhausted, in
pain, stunned by the rapid nature of the delivery, or simply following cultural
norms. Providing support to the mother is the most appropriate and
therapeutic action by the nurse.

• As the placenta separates, the uterus changes from a discoid to a globular

shape. Other signs of placental separation include lengthening of the
umbilical cord, a sudden gush of dark blood from the introitus, and a firmly
contracted uterus. The client may experience vaginal fullness, but not sudden
abdominal pain.

• The lower uterine segment does not contain the same intertwining
musculature as the fundus of the uterus, making this site more prone to
postpartum bleeding.

• The client most at risk for abruptio placenta is the woman who smokes or
uses alcohol, illegal drugs such as cocaine, or caffeine during pregnancy.

• The normal fetal heart rate is 120 to 160 beats/minute. Signs of

potential complications of labor include contractions consistently
lasting 90 seconds or longer, contractions consistently occurring 2
minutes or less apart, fetal bradycardia, tachycardia, persistently
decreased variability, or an irregular FHR.

• Breath sounds are the best way to assess the onset of heart failure.
The presence of crackles or rales or an increase in crackles is an
indicator of fluid in the lungs caused by heart failure.

• A positive reaction to a tuberculin skin test indicates exposure to tuberculosis

infection. Because the response to tuberculin skin testing may be decreased
in the immunosuppressed client, induration reactions more than 5 mm are
considered positive. A reading of 6-mm induration is a positive result in a
client who is HIV positive. A positive result indicates exposure to tuberculosis
and possibly the development of tuberculin infection. Further diagnostic tests
should be performed to confirm infection with tuberculosis.

• The TNM classification system for staging tumors is widely used. T refers to
the tumor size, with T0 indicating no primary tumor found and T1 to T4
referring to progressively larger tumors. TIS is used to indicate a carcinoma in
situ. N refers to regional lymph node involvement. N0 indicates regional

21
 nodes were normal, and N1 to N4 indicates increasingly abnormal regional
lymph nodes. M1 indicates that distant metastasis is present.

• The complications associated with thoracic surgery include pulmonary

edema, cardiac dysrhythmias, hemorrhage, hemothorax, hypovolemic shock,
and thrombophlebitis. Signs of pulmonary edema include dyspnea, crackles,
persistent cough, frothy sputum, and cyanosis. A urinary output of 45
mL/hour is an appropriate output. The nurse would become concerned if the
output were below 30 mL/hour. Between 100 and 300 mL of drainage may
accumulate during the first 2 hours after thoracic surgery. Normal arterial
blood pH is 7.35 to 7.45. An arterial blood pH of 7.35 is not indicative of a
complication.

• The client with Raynaud’s disease suffers from body-image disturbance when
physical changes begin to occur. Therapeutic nursing interventions are
implemented to encourage verbalization about the body changes and to
develop appropriate problem-solving techniques for coping with the changes.

• Specific gravity is a measure of the concentration of particles in the urine. A

normal range of urine specific gravity is approximately 1.005 to 1.030. Early
in polycystic kidney disease, the ability of the kidneys to concentrate urine
decreases. A urine specific gravity of 1.000 is lower than normal, indicating
dilute urine.

• Giving the client with chronic emphysema a high liter flow of oxygen could
stop the hypoxic drive and cause apnea.

• Assays of catecholamines are performed on single-voided urine specimens, 2-

to 4-hour specimens, and 24-hour urine specimens. The normal range of
urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels
occurring in pheochromocytoma.

• After a cerebrovascular accident, clients are often emotionally labile,

confused, forgetful, and frustrated. Clients may use profanity, which is often
termed “automatic language.”

• The complications associated with severe scoliosis interfere with respiration.

The lungs may not fully expand as a result of the severe curvature of the
spine. Atelectasis and dyspnea are complications that can occur as a result of
a decrease in lung expansion.

• The purpose of a venogram is to assess the severity of venous obstruction.

The test will locate obstructions and/or thrombi by x-ray films after a
radiopaque dye is injected into a vein that has been previously emptied by
gravity. This test is a diagnostic procedure and will not eliminate leg

22
 problems or determine whether the support stockings can be discontinued.
Injections can cause discomfort.

• The complications associated with pheochromocytoma include hypertensive

retinopathy and nephropathy, myocarditis, congestive heart failure (CHF),
increased platelet aggregation, and cerebrovascular accident (CVA). Death
can occur from shock, CVA, renal failure, dysrhythmias, and dissecting aortic
aneurysm. Rales heard on auscultation are indicative of CHF.

• In myxedema, the TSH level is elevated, and the T3 and T4 levels are
decreased. Secretion of T3 and T4 is regulated by a hypothalamic-
pituitary-thyroid gland feedback mechanism. TSH regulates the
secretion of thyroid hormone from the thyroid gland. The circulating
levels of thyroid hormone are the major factor regulating the release
of TSH. If the thyroid levels are low, TSH release is increased, and if
the thyroid levels are high, TSH is inhibited. In hyperthyroidism, T3
and T4 secretions are elevated because the normal regulatory
controls of thyroid hormone are lost. Hypoparathyroidism is
associated with a decrease in serum calcium and an increase in
serum phosphate.

• Cutting the blood glucose monitoring strips in half may affect the accuracy in
reading the results.

• Hydrocortisone is the topical treatment of choice for cutaneous inflammation

and pruritus associated with contact dermatitis. If a rash does not respond to
this over-the-counter medication, it should be evaluated by a health care
provider.

• The client should be taught to take the pulse in the wrist or neck every day at
the same time, preferably in the morning, and to rest a full 5 minutes before
taking the pulse. The pulse is counted for 1 full minute by using a watch or
clock that has an accurate second hand. The pulse is recorded every day in a
log that indicates a description of the rate, rhythm, and date and time of day.
If a change in rate or rhythm is noted, the physician should be notified.

• Crutch tips should remain dry. Water could cause slipping by decreasing the
surface friction of the rubber tip on the floor. If crutch tips get wet, the client
should dry them with a cloth or paper towel. The client should use only
crutches measured for the client. The tips should be inspected for wear, and
spare crutches and tips should be available if needed.

• The normal random blood glucose level is 70 to 115 mg/dL but may vary
depending on the time of the last meal.

23
• On removal of a chest tube, an occlusive dressing consisting of petrolatum
gauze covered by a dry sterile dressing is usually placed over the chest tube
site dressing. This is maintained in place until the physician states it may be
removed. Monitoring and reporting respiratory difficulty and increased
temperature are appropriate client activities on discharge. The client should
avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate
continued wound healing.

• Postoperative care after a parathyroidectomy includes instructing the client

that the weight of the client’s head must be supported when the client flexes
the neck or moves the head. This decreases the stress on the suture line,
which prevents bleeding.

• Boiling the vegetables and discarding the water can decrease the potassium
content of vegetables. Bananas and oranges are high in potassium and
should be avoided. Meats contain some potassium and are high in protein
and should be limited to 6 oz/day. Salt substitutes are often high in
potassium and are to be avoided.

• Plasmapheresis is a process that separates the plasma from the blood

elements, so that plasma proteins that contain antibodies can be removed. It
is used as an adjunct therapy in myasthenia gravis and may give temporary
relief to clients with actual or impending respiratory failure. Usually three to
five treatments are required. Improvement in vital (respiratory) capacity is an
intended effect of this treatment.

• The client with CAL should use energy-conservation techniques to conserve

oxygen. These include sitting to perform many household chores or activities,
and alternating activity with rest periods. The client should avoid raising the
arms above the head, because use of the arms could increase dyspnea. The
client should never hold the breath during an activity.

• When a client is placed in pelvic traction, the foot end of the bed is
raised to prevent the client from being pulled down in bed by the
traction. The head of the bed is usually kept flat, and the client is
maintained in good body alignment. The girdle or belt should be
applied snugly so it does not slip off of the client, and therefore the
skin should be checked for pressure sores.

• Traditional treatment of a UTI involves 7 to 10 days administration of oral

antimicrobial therapy. It is important to take antibiotics, even if the client is
feeling better. While taking these medications, the client should drink at least
eight glasses of fluid per day to keep urine dilute. Voiding regularly will flush
bacteria out of the bladder and urethra. Teaching the client to cleanse the
perineal area from front to back helps to prevent urinary tract infection.

24
• The cane is held on the stronger side to minimize stress on the affected
extremity and provide a wide base of support. The cane is held 6 inches
lateral to the fifth toe. The cane is moved forward with the affected leg. The
client leans on the cane for added support while the stronger side swings
through.

• Older and immunocompromised clients may not have a positive reaction to

the initial tuberculin skin test, even if they had prior exposure to the tubercle
bacillus. If the test is negative (no reaction), the client may have a delayed
reaction and should have a repeated tuberculin skin test in 1 to 2 weeks. The
second test should reveal positive results if the client had prior exposure. The
tuberculin skin test is read in 48 to 72 hours. Erythema or redness alone is
not considered significant. The size of induration, if any, is what determines
the significance of the test. A positive test does not indicate active disease.
Persons with a positive reaction are followed up with a chest radiograph.

• After restoring circulation to the affected limb, the nurse reinforces teaching
that was done after the original surgery. This includes exercise and dietary
recommendations, as well as instructions on foot care and prevention of
injury to the limb. The client should check the condition of the leg and foot
every day. Taking a baby aspirin every day does not ensure that further
complications will not occur. Walking will be a component of the treatment
plan.

• Instructions to a client after a aorto-iliac bypass grafting about measures to

improve circulation while in the hospital includes clot formation in the graft
can result from any form of pressure that impairs blood flow through the
graft, including bending at the hip or knee, crossing the knees or ankles, or
use of the knee gatch or pillows. All of these actions are avoided in the
postoperative period.

• The presence of multiple organisms in a urine culture usually indicates that

contamination has occurred. The urinary tract is normally sterile, and
infection, if it occurs, is usually with one organism. A repeat of the urine
culture is indicated.

• Spinal shock that occurs after spinal cord injury lasts 3 to 6 weeks after the
injury and is characterized by a flaccid neurogenic bladder with urinary
retention. Intermittent catheterization used to empty the bladder should be
carried out in a manner that prevents urinary tract infection (UTI). Cloudy or
blood-tinged urine may indicate the onset of infection. Because fluid is lost
through the skin, lungs, and bowel, intake does not normally equal output.
Sensations of the need to void require an intact cord, which would not be
present in this client. Cholinergic action stimulates bladder emptying, so

25
 anticholinergics would produce the undesirable effect of relaxation of the
bladder in this client.

• First-degree heart block indicates a delayed conduction somewhere between

the junctional tissue and the Purkinje network, causing a prolonged PR
interval. Lying still will not relieve the problem. A pacemaker is not necessary
for first-degree heart block. Medication may be prescribed to treat this
condition.

• The client should use the walker by placing the hands on the handgrips for
stability. The client lifts the walker to advance it, and leans forward slightly
while moving it. The client walks into the walker, supporting the body weight
on the hands while moving the weaker leg. A disadvantage of the walker is
that it does not allow reciprocal walking motion. If the client were to try to
use reciprocal motion with a walker, the walker would advance forward one
side at a time as the client walks; thus the client would not be supporting the
weaker leg with the walker during ambulation.

• Within 2 or 3 days of surgery, a lung is generally fully re-expanded. The nurse

notes an absence of fluctuation or bubbling in the water seal chamber or
drainage from the chest tube. At this time, the client’s status is confirmed by
chest x-ray. If the lung is fully re-expanded, the physician may remove the
chest tube.

• The irreversible stage of cardiogenic shock represents the point along the
shock continuum when organ damage is so severe that the client does not
respond to treatment and is unable to survive. Multiple organ failure has
occurred, and death is imminent. As it becomes obvious that the client is
unlikely to survive, the client’s family needs to be informed about the
prognosis and outcome. Support to the grieving family members becomes an
integral part of the nursing care plan.

• The purpose of ECG monitoring is to record cardiac electrical activity during

the depolarization and repolarization phases. The two types of single-lead
monitoring are hardwire and telemetry. With a wireless battery-operated
telemetry system, the client is afforded more freedom and mobility than with
the hardwire system. The most common problems with ECG monitoring are
related to client movement, electrical interference from equipment in the
room, poor choice of monitoring leads, and poor contact between the skin
and electrode.

• Tracheostomy dressings should be changed whenever they get wet or damp.

A soiled dressing promotes microorganism growth and enhances tissue
irritation and skin breakdown. The oxygen collar may be cleaned if it
becomes soiled between collar and tubing changes, which are done every 24

26
 hours. Tracheostomy care should be done at least every 8 hours or per
agency policy. It would not be beneficial to the client to limit fluids, because
thicker secretions pose added problems with airway management.

• Before discharging a ventilator-dependent client to home, the nurse

determines that the family is able to perform CPR, including mouth-to-
tracheostomy ventilation. The CPR course designed for lay people in the
community does not include this element of care. The electrical service to the
home must be sufficient for the equipment that will be used. The ventilator
should have a built-in converter to battery power if the electrical power
should fail. Otherwise, a generator must be installed. The home itself should
be free of drafts and provide adequate air circulation.

• Back pain after AAA repair may indicate a problem with the repair. It should
be reported to the physician immediately.

• Disease processes, such as cirrhosis, damage the blood flow through the
liver, resulting in hypertension in the portal venous system. The increased
portal pressure causes esophageal varices, which are swollen and distended
veins. Factors such as increased intrathoracic pressure or irritations can
cause these varices to rupture with subsequent hemorrhage.

• Cryosurgery entails freezing cervical tissue with nitrous oxide. It is performed

in an outpatient setting. Cryosurgery may result in cramping and a vasovagal
response that may cause faintness. A watery discharge is normal for a few
weeks after the procedure.

• The client who experiences epididymitis from a urinary tract infection should
increase the intake of fluids to flush the urinary system. Because organisms
can be forced into the vas deferens and epididymis from strain or pressure
during voiding, the client should limit the force of the urinary stream.
Condom use can help to prevent epididymitis that can occur as a result of
STDs. Antibiotics are always taken until the full course of therapy is
completed.

• Treatment of prostatitis includes medication with antibiotics, analgesics, and

stool softeners. The client also is taught to rest, increase fluid intake, and use
sitz baths for comfort. Antimicrobial therapy is always continued until the
prescription is completely finished.

• The client with respiratory disease may have Ineffective Coping related to the
inability to tolerate activity and social isolation. The client demonstrates
adaptive responses by increasing the activity to the highest level possible
before symptoms are triggered, using relaxation or other learned coping
skills, or enrolling in a pulmonary rehabilitation program.

27
• The primary symptom in placenta previa is painless vaginal bleeding in the
second or third trimester of pregnancy. Passage of the mucus plug appears
pink or as blood-tinged mucus. A ruptured amniotic sac would include
findings such as a watery vaginal drainage. Findings of abruptio placenta
include dark red vaginal bleeding and abdominal pain.

• Magnesium sulfate depresses the respiratory rate. If the respiratory rate is

less than 12 breaths per minute, the continuation of the medication should
be reassessed.

• The symptoms of jitteriness and tachypnea (respiratory rate of 62 breaths

per minute) in a 42-week-gestation newborn infant are indicative of
hypoglycemia. Hypoglycemia may develop in a 42-week-gestation newborn
infant because of the insufficient stores of glycogen, which may have been
depleted during the post-term period. Insufficient amounts of glucose in the
infant’s brain could possibly cause central nervous system damage.

• A normal blood glucose level for newborn infants is 40 mg/dL and

higher.

• Rho(D) immune globulin is not administered if a client has experienced a

severe reaction to its component, human globulin. Rho(D) immune globulin is
indicated when Rh-negative clients are exposure to Rh-positive fetal blood
cells in any way, including amniocentesis and abortion.

• A person who lacks hope feels that life is too much to handle. By seeing no
way out of the situation except death, the client meets the criteria for
hopelessness.

• Abdominal exercises should not be started after abdominal surgery until 3 to

4 postoperative weeks to allow healing of the incision.

• Coagulation failure, particularly disseminated intravascular coagulopathy

(DIC), is a common result of an amniotic fluid embolus. Manifestations are
internal and external hemorrhage clinically determined by bleeding at the
site of any trauma (pressure, needle prick, or incision), and petechiae
resulting from slight to moderate touch.

• A postpartum woman who saturates a Peripad in 15 minutes or less is

considered to be hemorrhaging, which in this case is caused by lack of
coagulation at the placental site.

• A pulsating rope-like object seen in the vagina indicates the presence of the
umbilical cord. Each contraction will press the presenting part downward
against the bony pelvis, applying pressure to the prolapsed cord,
compressing it between the presenting part and the bony pelvis. The

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 compression will shut off the fetal circulation at the point of compression,
leading to impaired fetal tissue perfusion and hypoxia of the fetus.

• Situational Low Self-Esteem represents temporary negative feelings about

self in response to an event. This is a normal response to cesarean section.

• Pregnancy taxes the circulating system of every woman because both the
blood volume and cardiac output increase approximately 30%. This is
especially important to monitor in the client whose heart may not tolerate
this normal increase.

• HIV has a strong affinity for surface marker proteins on lymphocytes. This
affinity of HIV for T lymphocytes leads to significant cell destruction.
Angiotensin is produced in the kidney and plays a role in blood pressure
control.

• HIV infection in a pregnant woman may cause both maternal and fetal
complications. Fetal compromise can occur because of premature rupture of
the membranes, preterm birth, or low birth weight. Potential maternal effects
include an increased risk of opportunistic infections. Individuals in the later
stages of HIV are further susceptible to other invasive conditions, such as
tuberculosis and a wide variety of bacterial infections.

• The anterior fontanel is normally 2.5 to 5 cm in width and diamond-like in

shape. It can be described as soft, which is normal, or full and bulging, which
could be indicative of increased intracranial pressure. Conversely, a
depressed fontanel could mean that the neonate is dehydrated.

• Clients with Cushing’s syndrome experience weight gain with truncal obesity.
The extremities appear thin with the presence of muscle wasting and
weakness. The skin is often described as being thin and translucent. A
butterfly rash across the cheeks of the face is seen in systemic lupus
erythematosus. Polydipsia and polyphagia are seen in diabetes mellitus.
Weight loss and peripheral edema may be seen in a number of conditions.

• Situations that precipitate sickle cell crisis include hypoxia, vascular stasis,
low environmental and/or body temperature, acidosis, strenuous exercise,
anesthesia, dehydration, and infections.

• The client undergoing radiation therapy should avoid washing the

site until instructed to do so. The client should then wash with mild
soap and warm or cool water, and pat the area dry. No lotions,
creams, alcohol, or deodorants should be placed on the skin over the
treatment site. Lines or ink marks that are placed on the skin to
guide the radiation therapy should be left in place. The affected skin

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 should be protected from temperature extremes, direct sunlight,
and chlorinated water (as from swimming pools).

• Prevention of recurrence of urinary stones is accomplished by drinking at

least 3 L of fluid per day; voiding every 2 hours; following an acid ash diet if
the stones are calcium oxalate stones; and notifying the physician promptly if
symptoms of UTI occur.

• The client with polycystic kidney disease should report any signs and
symptoms of urinary tract infection so that treatment may begin promptly.
The client should also report increases in blood pressure, because control of
hypertension is essential. The client may experience heart failure as a result
of hypertension, and thus any symptoms of heart failure, such as shortness of
breath, also are reported.

• The goal of therapy in nephrotic syndrome is to heal the leaking glomerular

membrane. This would then control edema by stopping loss of protein in the
urine. Fluid balance and albumin levels are monitored to determine
effectiveness of therapy.

• Stair climbing may be restricted or limited for several weeks after spinal
fusion with instrumentation. The nurse assures that resources are in place
before discharge so that the client may sleep and perform all activities of
daily living on a single living level.

• The skin under a casted area may be discolored and crusted with dead skin
layers. The client should gently soak and wash the skin for the first few days.
The skin should be patted dry, and a lubricating lotion should be applied.
Clients often want to scrub the dead skin away, which irritates the skin. The
client should avoid overexposing the skin to the sunlight.

• Expected outcomes for Impaired Physical Mobility for the client in traction
include absence of thrombophlebitis (measurable by negative Homans' sign),
active baseline ROM to uninvolved joints, clear lung sounds, intact skin, and
bowel movement every other day.

• After three unsuccessful defibrillation attempts, CPR should be done for 1

minute, followed by three more shocks, each delivered at 360 joules.

• Typical discharge activity instructions for the first 6 weeks include lifting
nothing heavier than 5 pounds, not driving, and avoiding any activities that
cause straining. The client is taught to use the arms for balance, but not
weight support, to avoid the effects of straining. These limitations are to
allow sternal healing, which takes approximately 6 weeks.

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• Clients can resume sexual activity on the advice of a physician, which
generally occurs when the client can walk one block and climb two flights of
stairs without discomfort. Suggestions to minimize potential problems include
waiting for 2 hours after meals or alcohol consumption, making sure one feels
well rested, using a comfortable position, and keeping the room at a mild (not
chilly) temperature.

• Expected outcomes for the client with pulmonary edema include improved
cardiac output as evidenced by stable vital signs, and urine output of at least
30 mL/hour.

• The client’s blood gas results indicate respiratory acidosis. Symptoms of

respiratory acidosis include headache, irritability, muscle twitching,
behavioral changes, confusion, lethargy, and coma.

• When the carboxyhemoglobin levels are greater than 25% (acute toxicity),
the respiratory center becomes depressed because of inadequate
oxygenation, and hypoxia occurs.

• A long-range approach to the prevention of pulmonary edema is to minimize

any pulmonary congestion. During recumbent sleep, fluid (which has seeped
into the interstitium by day with the assistance of the effects of gravity) is
rapidly reabsorbed into the systemic circulation. Sleeping with the head of
the bed elevated helps prevent circulatory overload.

• Complications after pleural biopsy include hemothorax, pneumothorax, and

temporary pain from intercostal nerve injury. The nurse notes indications of
these complications, such as dyspnea, excessive pain, pallor, or diaphoresis.
Mild pain is expected, because the procedure itself is painful.

• The nurse teaches the client that the pain of fractured ribs generally lasts for
about 5 to 7 days. Full healing takes about 6 weeks, after which full activity
may be resumed.

• Coughing and deep breathing will effectively promote lung expansion and
clearance of mucus. Using an incentive spirometer is helpful, but it is most
effective if the client uses it independently without coaching. The nurse may
not need to suction the client if the client is not intubated

• Prinzmetal’s angina results from spasm of the coronary vessels. The risk
factors are unknown, and it is relatively unresponsive to nitrates. Beta
blockers may worsen the spasm.

• Exercise is most effective when done at least 3 times a week for a client with
angina pectoris. Other positive habits include limiting salt and fat in the diet,

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 using stress-management techniques, and knowing when and how to use
medications.

• Nosebleeds may occur during the winter because of decreased humidity in

the home. The use of a humidifier helps to alleviate this problem.

• If pulse oximeter values fall below a preset norm, which is usually 90% to
91%, the client should be instructed to take several deep breaths. This is
especially true of a client without a respiratory history who is still under the
effects of sedation. If the client did have a respiratory disease history, it
might be an indication that supplemental oxygen should be put in place or
increased if already in place.

• A Gram stain classifies the organism as gram-negative or gram-

positive, and may be done immediately by the laboratory. This gives
initial information about the type of organism when initiation of
antibiotic therapy is a high priority. The specimen is then incubated
on a culture medium for at least 24 hours more to identify the
specific organism(s). The sensitivity test gives the physician precise
information about which antibiotics the organism is sensitive to.

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