Results for Reduction of Risk Potential

 Questions are numbered by the order in which they appeared in the

 * Represents the correct answer.

Question 1
A four year-old has been hospitalized for 24 Answers Correct A
hours with skeletal traction for treatment of a Student's A
fracture of the right femur. The nurse finds
that the child is now crying and the right foot
is pale with the absence of a pulse. What
should the nurse do FIRST?
* A) Notify the physician
B) Readjust the traction
Administer the ordered prn
C)
medication
D) Reassess the foot in fifteen minutes
Review Information: The correct answer is:
A) Notify the physician.

The findings are indicative of circulatory impairment. The physician (or

practitioner) must be notified immediately.

Wong, D. (1999).
Whaley & Wong''s Nursing Care of Infants and Children..
St. Louis: Mosby. p. 1830

Ball, J. & Bindler, R. (2000).

Pediatric Nursing: Caring for Children.
Norwalk: Appleton & Lange. p. 613

Question 2
A client has a history of chronic obstructive Answers Correct C
pulmonary disease (COPD). As the nurse Student's C
enters the client's room, his oxygen is running
at 6 L/min, his color is flushed and his
respirations are 8/min. What should the nurse
do FIRST?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
* C) Lower the oxygen rate
D) Take baseline vital signs
Review Information: The correct answer is:
C) Lower the oxygen rate.

A low oxygen level acts as a stimulus for respiration. A high

concentration of supplemental oxygen removes the hypoxic drive to
breathe, leading to increased hypoventilation, respiratory
decompensation, and the development of or worsening of respiratory
acidosis. Unless corrected, it can lead to the client''s death.

Nettina, Sandra (2000).

The Lippincott Manual of Nursing Practice. Sixth Edition.
Lippincott. Philadelphia - New York. 1996. Page 234-239.

Luckmann, Joan.
Saunders Manual of Nursing Care.
W.B. Saunders Company. Philadelphia. 1997. Page 921-929.

Question 3
The nurse is assessing a client two hours Answers Correct C
postoperatively after a femoral popliteal Student's B
bypass. The upper leg dressing becomes
saturated with blood. The nurse's FIRST
action should be to
A) Wrap the leg with elastic bandages
B) Apply pressure at the bleeding site
Reinforce the dressing and elevate the
* C)
leg
Remove the dressings and re-dress the
D)
incision
Review Information: The correct answer is:
C) Reinforce the dressing and elevate the leg.

Reinforce the dressing, elevate the extremity to decrease blood flow into
the extremity and thus decrease bleeding, and call the physician
immediately. This is an emergency post surgical situation.

Black, J., Matassarin-Jacobs, E. (1997).

Medical-Surgical Nursing: Clinical Management for Continuity of Care
(5th ed.).
Philadelphia: Saunders.

Lewis, S., Collier, I., & Heitkemper, M. (1996).

Medical-Surgical nursing: Assessment and management of clinical
problems. (4th ed).
St. Louis: Mosby

Question 4
The nurse is caring for a client who requires a Answers Correct B
mechanical ventilator for breathing. The high Student's B
pressure alarm goes off on the ventilator.
What is the FIRST action the nurse should
perform?
Disconnect the client from the
A) ventilator and use a manual
resuscitation bag
Perform a quick assessment of the
* B)
client's condition
C) Call the respiratory therapist for help
Press the alarm re-set button on the
D)
ventilator
Review Information: The correct answer is:
B) Perform a quick assessment of the client''s condition.

A number of situations can cause the high pressure alarm to sound. It

can be as simple as the client coughing. A quick assessment of the client
will alert the nurse to whether it is a more serious or complex situation
that might then require using a manual resuscitation bag and calling the
respiratory therapist.

Milikowski K.
What those ventilator alarms mean. RN 1995;58

:29.
Carroll P. A med/surg nurse''s guide to mechanical ventilation. RN
1995;58

:26-31.

Question 5
The nurse is reviewing laboratory results on a Answers Correct D
client with acute renal failure. Which one of Student's D
the following should be reported
IMMEDIATELY?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
* D) Serum potassium 6 mEq/L
Review Information: The correct answer is:
D) Serum potassium 6 mEq/L.

Although all of these findings are abnormal, the elevated potassium is a

life threatening finding and must be reported immediately.

Lewis, S., Collier, I., & Heitkemper, M. (1996).

Medical-Surgical Nursing. (4th ed.).
St. Louis: Mosby-Yearbook. p.1374

Black, J. & Matassarin-Jacobs, E. (1997).

Medical-Surgical Nursing.
Philadelphia: W. B. Saunders. p. 32

Question 6
A client has a chest tube in place following a Answers Correct D
left lower lobectomy done after a stab wound Student's D
to the chest. When repositioning the client,
the nurse notices 200 cc of dark, red fluid
flows into the collection chamber of the chest
drain. What is the MOST appropriate nursing
action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
Continue to monitor the rate of
* D)
drainage
Review Information: The correct answer is:
D) Continue to monitor the rate of drainage.

Blood that comes in contact with the pleural space becomes

defibrinogenated and usually will not clot. It is not unusual for blood to
collect in the chest and be released into the chest drain when the client
changes position. The dark color of the blood indicates it is not fresh
bleeding inside the chest.

Carroll P: Chest tubes made easy. RN 1995;58(12):46-55.

Carroll P: Salvaging blood from the chest. RN 1996;59(9):32-38.

Question 7
When caring for a client with a post right Answers Correct B
thoracotomy who has undergone an upper Student's B
lobectomy, the nurse focuses on pain
management to promote
A) Relaxation and sleep
* B) Coughing and deep breathing
C) Incisional healing
D) Range of motion exercises
Review Information: The correct answer is:
B) Coughing and deep breathing.

The priority is postoperative respiratory toilet. This client will quickly

develop profound atelectasis and eventually pneumonia without
adequate gas exchange. This will only be achieved with the appropriate
pain management.

Black, J., Matassarin-Jacobs, E. (1997).

Medical-Surgical Nursing: Clinical Management for Continuity of Care
(5th ed.).
Philadelphia: Saunders.

Lewis, S., Collier, I., & Heitkemper, M. (1996).

Medical-Surgical nursing: Assessment and management of clinical
problems. (4th ed).
St. Louis: Mosby

Question 8
The nurse is caring for a client undergoing Answers Correct C
the placement of a central venous catheter Student's C
line. Which of the following would require
the nurse’s IMMEDIATE attention?
A) Pallor
B) Increased temperature
* C) Dyspnea
D) Involuntary muscle spasms
Review Information: The correct answer is:
C) Dyspnea.

Client’s having the insertion of a central venous catheter are at risk for
tension pneumothorax. Dyspnea, shortness of breath and chest pain are
indications of this complication.

Medical-Surgical Nursing: A Nursing Process Approach, Third Edition,

1993
AHA, Textbook of ACLS, Fourth Edition

Black, J. and Matassarin-Jacobs, E. (1997)

medical-Surgical Nursing (5th ed.).
Philadelphia: W. B. Saunders. P. 1524.

Question 9
The nurse is performing a physical Answers Correct C
assessment on a client who just had an Student's C
endotracheal tube inserted. Which finding
would call for IMMEDIATE action by the
nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
* C) Pulse oximetery of 88
D) Client is unable to speak
Review Information: The correct answer is:
C) Pulse oximetery of 88.

Pulse oximetry should not be lower than 90.

Black, M. & Matassarin Jacobs, E. (1997).

Medical Surgical Nursing. (5th ed.).
Philadelphia: Saunders, page 1174.

Potter, P. & Perry, A. (2000).

Fundamentals of Nursing.
St. Louis: Mosby. page 1254.

Question 10
A client is receiving external beam radiation Answers Correct B
to the mediastinum for treatment of bronchial Student's B
cancer. Which of the following should take
PRIORITY in planning care?
A) Esophagitis
* B) Leukopenia
C) Fatigue
D) Skin irritation
Review Information: The correct answer is:
B) Leukopenia.

Clients develop leukopenia due to the depressant effect of radiation

therapy on bone marrow function. Infection is the most frequent cause
of morbidity and death in clients with cancer.

Beare, P.G., Meyers J.L., (1998).

Adult Health Nursing (3rd ed.).
New York: Mosby.
Smeltzer, S.G., Bare, B.G. (1999).
Brunner and Suddarth''s Textbook of Medical - Surgical Nursing (8th
ed.).
New York: Lipppincott.

Question 11
A client is diagnosed with a spontaneous Answers Correct B
pneumothorax necessitating the insertion of a Student's B
chest tube. What is the BEST explanation for
the nurse to provide this client?
"The tube will drain fluid from your
A)
chest."
"The tube will remove excess air from
* B)
your chest."
"The tube controls the amount of air
C)
that enters your chest."
"The tube will seal the hole in your
D)
lung."
Review Information: The correct answer is:
B) "The tube will remove excess air from your chest.".

The purpose of the chest tube is to create negative pressure and remove
the air that has accumulated in the pleural space.

Bordow, R.A., & Moser, K.M. (1991).

Manual of Clinical Problems in Pulmonary Medicine.
Boston: Little, Brown.

Dettenmeier, P.A. (1992).

Pulmonary Nursing Care.
St. Louis: Mosby
Question 12
The nurse is caring for a child immediately Answers Correct B
after surgical correction of a ventricular Student's B
septal defect. Which of the following nursing
assessments should be a PRIORITY?
A) Blanch nail beds for color and refill
* B) Assess for post operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses
Review Information: The correct answer is:
B) Assess for post operative arrhythmias.

The atrioventricular bundle (bundle of His), a part of the electrical

conduction system of the heart, extends from the atrioventricular node
along each side of the interventricular septum and then divides into right
and left bundle branches. Surgical repair of a ventricular septal defect
consists of a purse-string approach or a patch sewn over the opening.

Wong, D. (1999).
Whaley and Wong''s Nursing Care of Children.
St. Louis: Mosby. page 1496, 1520.

Ball, J. & Bindler, R. (2000).

Pediatric Nursing: Caring for Children.
Norwalk: Appleton & Lange. pages 387.

Question 13
The MOST effective nursing intervention to Answers Correct B
prevent atelectasis from developing in a post Student's B
operative client is to
A) Maintain adequate hydration
Assist client to turn, cough and deep
* B)
breathe
C) Ambulate client within 12 hours
D) Splint incision
Review Information: The correct answer is:
B) Assist client to turn, cough and deep breathe.
Deep air excursion by turning, coughing, and deep breathing will
expand the lungs and stimulate surfactant production. The nurse should
instruct the client on how to splint the chest when coughing.
Humidification, hydration and nutrition all play a part in preventing
atelectasis following surgery.

Luckmann, Joan.
Saunders Manual of Nursing Care.
W.B. Saunders Company. Philadelphia. 1997. Page 933, 934.

Springhouse. Illustrated Handbook of Nursing Care.

Springhouse Corporation.
Springhouse, PA 1998. Pages 75-76.

Question 14
The nurse is preparing a client who will Answers Correct B
undergo a myelogram. Which of the Student's B
following statements by the client indicates a
contraindication for this test?
"I can't lie in one position for more
A)
than thirty minutes."
* B) "I am allergic to shrimp."
C) "I suffer from claustrophobia."
"I developed a severe headache after a
D)
spinal tap."
Review Information: The correct answer is:
B) "I am allergic to shrimp."

A client undergoing myelography should be questioned carefully about

allergies to iodine and iodine-containing substances such as seafood. An
allergy to iodine or seafood may indicate sensitivity to the radiopaque
contrast agent used in the test. An allergy to iodine or seafood may
indicate sensitivity to the radiopaque contrast agent used in the test. An
allergic reaction could be as serious as seizures.

Luckmann, Joan. (1997).

Suanders Manual of Nursing Care.
Philadelphia: W.B. Saunders Company. Page 1583-1586.

Springhouse. (1998).
Handbook of Medical-Surgical Nursing. (2nd ed.).
Springhouse, PA: Springhouse Corporation. Page 399-402.
Question 15
A client has returned from a cardiac Answers Correct C
catheterization. Which one of the following Student's C
assessments would indicate the client is
experiencing a complication from the
procedure?
A) Increased blood pressure
B) Increased heart rate
* C) Loss of pulse in the extremity
D) Decreased urine output
Review Information: The correct answer is:
C) Loss of pulse in the extremity.

Loss of the pulse in the extremity would indicate impaired circulation.

Lewis, S., Collier, I., & Heitkemper, M. (1996).

Medical-Surgical Nursing (4th ed.).
St. Louis: Mosby-Yearbook. p. 852

Black, J. & Matassarin-Jacobs, E. (1997).

Medical-Surgical Nursing.
Philadelphia: W. B. Saunders. p. 1231

REDUCTION OF RISK POTENTIAL

COMPLETE BLOOD COUNT

1. Red blood cell count

a. Men 4.7-6.1 million/mm3
b. Women 4.2-5.4 million/mm3
c. Infants and children 3.8-5.5 million/mm3
d. Newborns 4.8-7.1 million/mm3
2. White blood cell count
a. Adults and children > 2 years of age 5,000-10,000/cm3
b. Children > 2 years 6200-17,000/mm3
c. Newborns 9000-30,000/mm3
3. Hematocrit
a. Men 42-52%
b. Women 37-47% (pregnancy>33%)
c. Children 31-43%
d. Infants 30-40%
e. Newborns 44-64%
4. Hemoglobin
 a. Men 13.5-18.0 g/dl
b. Women 12-16 g/dl (pregnancy >11 g/dl)
c. Children 11-16 g/dl
d. Infants 10-15 g/dl
e. Newborns 14-24 g/dl
5. Erythrocyte indices
a. Mean corpuscular volume (MCV) 86-98 (m3/cell)
b. Mean corpuscular hemoglobin (MCH) 27-32 pg/RBC
c. Mean corpuscular hemoglobin concentrate. (MCHC) 32-36%
6. Differential white cell count
a. Neutrophils 55-70%
b. Lymphocytes 20-40%
c. Monocytes 2-8%
d. Eosinophils 1-4%
e. Basophils 0.5-1.0%
7. Examination of peripheral blood cells: examination of size and shape of
individual RBCs and platelets

Blood chemistry consists of the following:

Electrolytes, etc. Normal Value

1. Sodium 135-145 mEq/L
2. Potassium 3.5-5.3 mEq/L
3. Chloride 100-106 mEq/L
4. Calcium 4-5 mEq/L
5. Carbon Dioxide content 24-30 mEq/L
6. Magnesium 1.5-2.5 mEq/L
7. Phosphate 2.5-4.5 mEq/L
8. Serum osmolality 280-295 mOsm/kg

PLASMA VALUES

1. Albumin: 3.6-5.0 g/dl (see also Proteins, below)

2. Alcohol: negative
3. Alkaline phosphatase

Adults 30-85 ImU/ml

Children < 2 years 85-235 ImU/ml

2-8 years 65-210 ImU/ml

9-15 years 60-300 ImU/ml

4. Ammonia

Adults 9-33 µmol/liter

Children 40-80 g/dl

Newborns 90-150 g/dl

5. Alpha fetoprotein (AFP) <25 ng/ml

6. Bilirubin, direct - up to 0.3 mg/dl
7. Bilirubin, indirect - 0.1-1.0 mg/dl
8. Bilirubin total

Adults and children 0.3-1.1 mg/dl

Newborns 1-21 mg/dl

9. Bleeding time 1-9 minutes

10. Calcium 8.6-10.3 mg/dl
11. Chloride 97-110 mmol/liter
12. Creatinine 0.5-1.7 mg/dl
13. Creatinine clearance 107-139 ml/min - can vary by age
• Norms: 20 years .84 to 100 years .132
14. Fibrinogen 150-360 mg/dl
15. Gamma globulin 0.8-1.6 g/dl
16. Glucose fasting

Adults 65-115 mg/dl

Children 51-85 mg/dl

Newborns >24 hrs. 42-68 mg/dl

17. Glucose (2 hour postprandial) < 140 mg/dl

18. Glucose Tolerance Test
 Fasting 70-105 mg/dl; 30 minute < 200 mg/dl

1 hour < 200 mg/dl

2 hours < 140 mg/dl

3 hours 70-105 mg/dl

4 hours 70-105 mg/dl

19. Iron
• Male: 45-160 µg/dl
• Female: 30-160 µg/dl
20. Lead 120 (g/dl or less) <25 µg/dl
21. Lipids (total) 400- 800 mg/dl

α. Cholesterol <200 mg/dl

β. HDL
• Females: 30-85 mg/dl
• Males: 30-65 mg/dl
χ. LDL < 190 mg/dl
δ. Triglycerides <250
ε. Phospholipids 180-320 mg/dl
φ. Free Fatty Acids 9.0-15.0 mM/L
γ. Partial Thromboplastin time, activated (APTT) 21-32 seconds
η. Phosphorus

Adults 2.5-4.5 mg/dl

Children 3.5-5.8 mg/dl

ι. Potassium 3.8-5.0 mEq/L

ϕ. Protein (total) 6.2-8.2 g/dl

α. Albumin 3.6-5.0 g/dl

β. Globulin 2.3-3.4 g/dl
χ. Prothrombin Time (PT) 11.3-18.5 seconds
δ. Rheumatoid factor negative
ε. Sodium 135-145 mEq/L
φ. Thyroid tests
a. Thyroxine T44.5-12.0 µg/dl
b. TSH 0.35-6.20 µU/ml
c. Urea Nitrogen 8-25 mg/L
d. Uric acid 3-8 mg/dl

NORMAL BLOOD VALUES

1. Red cell volume 25-35ml/kg body weight
2. Platelets: 200,00-300,000/ml3
3. Erythrocyte Sedimentation Rate (ESR)
• Adults up to 30mm/hr
• Children up to 10 mm/hr
4. Arterial Blood gases

α. pH 7.35-7.45
β. PCO2 35-45 mm Hg
χ. HCO3- 22-26 mEq/L
δ. PO2 arterial 80-100 mm Hg
ε. Oxygen saturation 95-100%

NORMAL URINE VALUES

1. Acetone Negative
2. Specific gravity < 1.025
3. Osmolality 850 mOsm/L
4. Creatinine clearance
• Men 90-140 ml/min
• Women 85-125 ml/min
5. Glucose negative
6. Granular casts occasional
7. pH 4.6-8.0
8. Phenylketonuria negative
9. Protein negative
10. Sodium (24 hour) 100-260 mEq/24 hours
11. Urobilinogen 0.1-1.0 Ehrlich U/dl

COMMON LAB TESTS FOR NEUROLOGICAL DISORDERS:

CEREBROSPINAL FLUID

1. Appearance colorless, clear

2. Pressure 50-180 mm H2O
3. Protein
a. Lumbar 15-50 mg/dl
b. Cisternal 15-25 mg/dl
c. Ventricular 6-15 mg/dl
4. Cell Count
a. RBCs negative
b. WBCs 0-5
5. Glucose 50-80 mg/dl
6. Gram stain negative for organisms
7. Culture and sensitivity: no growth
COMMON LAB TESTS FOR MUSCULOSKELETAL DISORDERS: BLOOD
TESTS

1. ESR
2. C-reactive protein
3. CBC
4. Serum cultures
5. Serum Calcium

5. Uses
a. Diagnostic: permits inspection and obtaining biopsies
b. Therapeutic: remove polyps or foreign bodies, implant
radioactive seeds

Endoscopy Function Possible

Type Complications
Otoscopy Examine external auditory canal None
and middle ear
Rhinoscopy Examine the nasal cavity None
Laryngoscopy Examine the larynx None
Bronchoscopy Examine the larynx, trachea and Bronchospasm,
bronchi Bronchitis
Esophago-gastroscopy Examine the esophagus, Perforation of
stomach, and upper duodenum esophagus or
stomach
Colonoscopy Examine the colon Bowel perforation
Proctosigmoidoscopy Examine the anal canal, rectum, Bowel perforation
and sigmoid colon
Colposcopy Examine vagina and cervix with
a binocular microscope
Culdoscopy Examine the vagina and cervix None
by means of endoscope inserted
through posterior vaginal fornix
Hysteroscopy Examine cervical canal and Perforation of
uterine cavity uterus
Cystoscopy Examine urethra and bladder Dysuria,
hematuria; bladder
perforation
Laparoscopy Examine abdominal and pelvic Bleeding from
organs; fill abdomen with CO2 to puncture site
enhance vision
Pelvic endoscopy As above, with a fiberoptic light Bleeding from
 source inserted via laparoscope puncture site
Mediastinoscopy Examine the lung Bleeding from
puncture site
Thorascopy Examine the lung Bleeding from
puncture site
Arthroscopy Examine a joint Swelling of the
joint; bleeding into
the joint; infection

Procedures

A. General Nursing Interventions for All Procedures

1. Explain procedure to client and significant others
2. Obtain written consent when indicated by institutional policy
3. Allow client to ask questions, express concerns, fears
4. Help client relieve his or her anxiety
5. Involve significant others in procedure as appropriate
6. Carry out procedure according to institutional policy and procedure
7. Provide emotional support during procedure
8. Tell client what is going to happen during procedure
9. Post-procedure, observe for complications
10. Record all procedures and client's response to them
11. Obtain and label all specimens and send to lab for analysis
12. Document character of all specimens obtained
13. Maintain medical asepsis
14. Initiate standard precautions as indicated by CDC guidelines

B. Gastrointestinal Intubation
1. Routes
a. Nasopharynx: nasogastric, nasointestinal
b. Oropharynx
c. Through abdominal wall by incision: gastrostomy,
jejunostomy
d. Via endoscopy: percutaneous endoscopic gastrostomy
(PEG) or jejunostomy, (PEJ)
2. Requires a physician's order
3. Uses
a. Diagnostic
b. Gastric decompression
c. Gastric irrigation
d. Feeding

4. Nasogastric and nasointestinal

 a. Types of tube
1. Nasogastric
a. Single lumen: Levine
b. Salem
2. Nasointestinal
a. Single lumen: Cantor, Harris
b. Double lumen: Miller-Abbott
b. Complications of prolonged nasal intubation
1. Nasal erosion, sinusitis
2. Pharyngitis, esophagitis, esophageal sphincter
incompetence
3. Gastric ulceration, pulmonary aspiration
4. Aspiration risk is higher with nasal tubes
c. Nursing interventions in gastric or intestinal Intubation:

Before Intubation Intubation Care of Intubated

Process Client
1. Tube may be either 1. Insert but do not 1. Give frequent mouth
large-bore or small-bore force the tube and nose care
2. Before inserting 2. Check tube 2. Monitor fluid and
anything through the placement by electrolyte balance
nares, check for ausculating
patency, and for history stomach while you
of deviated septum, inject air into tube,
nosebleeds, or by checking pH
anticoagulant therapy. If of aspirate
history positive, confirm
insertion route with MD.
3. Remove client's 3. Monitor for signs of
dentures; place client in metabolic alkalosis
high Fowler's position;
have available ice chips
or glass of water for
client.
4. Measure for tube: 4. Record intake and
from tip of nose to ear output
lobe to xiphoid process
5. Implement standard 5. Watch for
precautions complications:
abdominal distention,
nausea, vomiting
6. Instruct client to bend 6. Monitor tube for
head forward, and to patency: aspirate tube,
swallow during insertion; check for kinks, irrigate
small sips of fluid or tube per MD's order
chips of ice may help

B. Gastrointestinal Intubation
1. Routes
a. Nasopharynx: nasogastric, nasointestinal
b. Oropharynx
c. Through abdominal wall by incision: gastrostomy,
jejunostomy
d. Via endoscopy: percutaneous endoscopic gastrostomy
(PEG) or jejunostomy, (PEJ)
2. Requires a physician's order
3. Uses
a. Diagnostic
b. Gastric decompression
c. Gastric irrigation
d. Feeding

C. Ostomy
1. Surgical procedure which creates an opening into the abdominal
wall for fecal or urinary elimination (enterostomy)
2. Portion of intestinal mucosa or ureter brought through abdominal
wall creating a stoma through which feces or urine drains
3. Types
a. Bowel: ileostomy or colostomy (illustration )
b. Urinary diversions
1. Ileal conduit (ileal loop)
2. Ureterostomies
4. Ileostomy
a. Stool is liquid, frequent, highly alkaline, contains digestive
enzymes
b. Requires constant pouching and frequent emptying
5. Colostomy: thicker, formed stool
a. Transverse colon: must be pouched at all times
b. Sigmoid colon: can be managed by daily irrigation, so no
need for pouch

6. Urinary diversions
a. Ileal loop or conduit
 1. A segment of the ileum is removed and used as a
passage for urine
2. One end forms a stoma on the abdominal wall, the
other is sutured closed
3. The ureters are implanted into the segment
4. A pouch is worn to collect urine
5. Remainder of bowel is reanastamosed. Client has
normal bowel movements through anus
6. Urine should be yellowish; may contain mucus
shreds
b. Continent urinary diversion
1. Reservoir for urine made from parts of small or
large bowel
2. Client needs no pouch
3. Reservoir is catheterized at specific times to drain
urine
c. Ureterostomy
1. One or both ureters are brought through the
abdominal wall to form a stoma(s)
2. Stomas are pouched to collect urine
3. Usually a temporary measure performed on infants
until ileal loop can be done
4. Complications include skin breakdown, infection,
necrosis

7. Nursing interventions for a client with ostomy; additional

guidelines for nursing care:
a. Empty pouches when they are about 1/3 to half full
b. If needed, protect skin around ileostomy stoma
c. Ostomies threaten body image. Do not force client to look
at stoma.
d. Fears of mutilation, shame, rejection are common
e. Clients may feel powerless because they cannot fully
control bodily functions
f. Assist client to establish normal elimination routine.
Observe client's tolerance of colostomy irrigation; report
immediately if:
1. Stoma oozes blood when touched
2. You see blood in pouch
3. You see bleeding from stoma
4. Urinary diversion puts out less than 30cc/hour
5. Urine smells foul
6. There is blood in urine, or it is very cloudy
 7. Client reports burning sensation around base of
urinary diversion stoma
8. Client reports back pain, chills, or fever
g. Teach client
1. The types of equipment and their use
2. How to irrigate colostomy
3. Prevention of complications
4. How to avoid constipation
5. That it is vital to drink plenty of fluids

5. Cast application
a. Cast must extend to the joint above and below the point of
fracture
b. Assessment prior to cast application
1. Skin: watch for irritation, laceration, skin
breakdown
2. Neurovascular status check
3. Edema/swelling
c. Windowing:
1. Square or diamond hole cut in cast over certain area
2. Indications
a. Observation of surgical incision
b. Observation of skin
c. Relieve pressure over bony prominence
3. Nursing interventions
a. Cast may crack at window site - weakest
part of the cast
b. Appropriate padding/petaling of open
window
d. Bivalving
1. Indications
a. Swelling
b. Infection or high potential for infection
c. Pain
2. Techniques
a. Lengthwise splitting of the cast with cast
saw
b. Apply ace wrap or tape to hold cast together
c. Still immobilizes
e. Petaling
1. Edging the cast with soft padding or moleskin
2. Indications
a. Prevent irritation or skin breakdown at
rough edges of cast
b. Protect cast from perspiration, feces, urine
c. Protect perineal area
6. Nursing interventions: Post cast application
a. Plaster of Paris casts
1. Handle fresh cast carefully (first 48 hours)
a. Indentations may cause pressure points
under the cast
b. Handle the cast with open palms of hands
2. Do not apply pressure to the cast
3. Do not cover the cast - allow to air dry
b. All Casts
1. Repeated neurovascular checks
a. Capillary refill time
b. Warmth
c. Color
d. Motion checks
i. Patient can move toes and fingers of
affected limb
ii. If not, a nerve is compressed
e. Sensation: numb or tingling may mean nerve
compressed
2. Drainage
a. Observe for wound drainage
b. Record size, color, amount; and circle area
on cast with felt tipped marker and date and
time
c. Check odor of drainage
3. Teach client
a. Keep cast dry and intact
b. To avoid placing any objects inside of or
through cast
c. Describe indications and therapeutic use of
casting for immobilization
d. Proper use of assistive devices
e. How to assess environment for potential
mobility hazards
f. To inspect cast daily for foul odor, cracks

7. Nursing interventions for cast removal with a mechanical saw

a. Explain procedure to client
b. Inform client that
1. Cast removal is painless
2. Client will feel heat and vibration
3. Saw is noisy but will not cut client
 4. Inspect tissue under cast for signs of inflammation
or infection
5. If skin is intact apply lotion to moisturize skin
c. Teach client
1. Underlying skin may be scaly and dry
2. To perform range of motion exercises as ordered
3. To use moisturizing lotion on dry skin

PRINCIPLES OF TRACTION

A. Maintain the prescribed line of pull

1. Especially important in patients with fractures
2. Maintain proper body alignment
B. Always maintain continuous pull UNLESS intermittent traction is
prescribed
C. Prevent Friction
1. Friction will alter the line of pull
2. Friction will impair the traction's efficiency
3. But NEVER lubricate pulleys
D. Identify and Maintain Countertraction
1. Counter traction is the force opposing the pull of traction
2. Generally provided by the patient's body
3. If counter traction is not maintained the patient is not in traction
4. Sign of loss of counter traction is that the patient slides down in bed
5. Especially problematic with Buck's Traction
6. Keep bed flat
7. Elevate the foot of the bed with shock blocks
E. Counter traction for pelvic traction is generally achieved by putting the bed
in the William position (both knees and hips are flexed at 30 degrees)

3. Types of Skin Traction:

Type of Traction Description Use

Bryant's Vertically held bilateral Usually used in
traction to legs children under 40
pounds
Buck's Extension Horizontally applied Used before repair of
unilateral or bilateral fractured hip or for
limb traction lumbosacral muscle
spasms
Cotrel's Head halter and pelvic Preoperative
belt pulling in opposite treatment for spinal
directions curvatures
 Dunlop's Horizontal Buck's Fractures or
Extension to humerus contractures of arm
with vertical Buck's or elbow
Extension to forearm
Pelvic Belt Girdle-type belt that fits Used for low back
around lumbosacral pain, muscle spasms,
area and ruptured nucleus
pulposus
Pelvic Sling Hammock-like sling Used for fractured
that cradles pelvis pelvis
Cervical Halter A strap under the chin Used for degenerative
or arthritic conditions
of cervical vertebrae
Russell's Traction Modified Buck's Fractures of femur; or
extension hip, knee disorders

G. Hemodialysis - Cleansing the blood of accumulated waste products

1. Uses
a. Short term therapy in acutely ill clients
b. Long term use in clients with end-stage renal disease
2. Hemodialysis requires five things
a. Access to patient's circulation (usually via fistula)
b. Access to a dialysis machine and dialyzer with a
semipermeable membrane
c. The appropriate solution (dialysate bath)
d. Time: 12 hours each week, divided in 3 equal segments
e. Place: home (if feasible) or a dialysis center
3. Three ways to access to client's circulation for dialysis:

Access Route for Abbreviation Description

Hemodialysis
Arteriovenous AVF A section of vein is directly
Fistula sutured to an artery. It is usually
placed in the nondominant arm,
using the cephalic vein and
radial artery
Arteriovenous Connection tube is client's own
Graft (autologous) saphenous vein, or
made from
polytetrafluoroethylene (PTFE)
Central Venous CVC Catheter inserted by directly
Catheter cannulating the vein. Usual CVC
sites are: femoral, internal
jugular, or subclavian veins
4. Procedure for hemodialysis
a. Patient's circulation is accessed
b. Unless contraindicated, heparin is administered (see
subcategory 8, page 14, Anticoagulants)
c. Heparinized (heparin: natural clot preventer) blood flows
through a semipermeable membrane in one direction
d. Dialysis solution surrounds the membranes and flows in the
opposite direction
e. Dialysis solution is:
1. Highly purified water
2. Sodium, potassium, calcium, magnesium, chloride
and dextrose
3. Either bicarbonate or acetate, to maintain a proper
pH
f. Via the process of diffusion, wastes are removed in the
form of solutes (metabolic wastes, acid-base components
and electrolytes)
g. Solute wastes can then be discarded or added to the blood
h. Ultrafiltration removes excess water from the blood
i. After cleansing, the blood returns to the client via the
access
5. Complications related to vascular access in Hemodialysis
a. Infection
b. Catheter clotting
c. Central venous thrombosis
d. Stenosis or thrombosis
e. Ischemia of the affected limb
f. Development of an aneurysm

6. Nursing interventions
a. Explain procedure to client
b. Monitor hemodynamic status continuously
c. Monitor acid-base balance
d. Monitor electrolytes
e. Insure sterility of system
f. Maintain a closed system
g. Discuss diet and restrictions on:
1. Protein intake
2. Sodium intake
3. Potassium intake
 4. Fluid intake
h. Reinforce adjustment to prescribed medications that may
be affected by the process of hemodialysis
i. Monitor for complications of dialysis related to:
1. Arteriosclerotic cardiovascular disease
2. Congestive heart failure
3. Stroke
4. Infection
5. Gastric ulcers
6. Hypertension
7. Calcium deficiencies (bone problems such as
aseptic necrosis of the hip joint)
8. Anemia and fatigue
9. Depression, sexual dysfunction, suicide risk

Anesthesia Description Use/Effect

Adjunct
Regional Techniques that render a Client remains conscious;
specific body area Anesthesia results from
insensitive to pain nerve block
Spinal Anesthetic injected into Blocks nerve transmission
subarachnoid space through spinal nerve roots;
(lower end of spinal cord) client remains conscious
Epidural Local anesthetic injected Common in obstetrics;
Anesthesia into epidural space client remains conscious
Peripheral Local anesthetic injected Provides anesthesia of
Nerve Blocks around a peripheral nerve area served by that nerve
Local Topic application or Provides anesthesia to
anesthesia infiltration of an local area
anesthetic agent

3. Complication of general anesthesia: Malignant hyperthermia

a. Rapid progressive rise in body temperature
b. Fatal if not treated
c. Signs and symptoms
1. Tachycardia
2. Tachypnea
3. Unstable blood pressure
4. Diaphoresis (sweating)
5. Muscle rigidity
d. Thought to be caused by alteration of calcium-storing
properties of muscle-cell membrane
 e. Familial tendency
f. Treatment - dantrolene (Dantrium): skeletal muscle
relaxant
g. Nursing interventions in Malignant hyperthermia
1. Administer medications as ordered
2. Teach client to wear medical alert jewelry

C. Postoperative Period I: Recovery and discharge home

1. Anesthesia recovery period - nursing interventions
a. Surgical Recovery: Fifteen Nursing Interventions - the
MPS's:

Care Category
0
Maintain Patent airway
Monitor Respiratory rate Stabilize vital signs For complications
and rhythm (see below)
Position Position client Keep side rails up When awake,
on side (unless at all times client should
contraindicated) change position
or on back with regularly
head to side
Provide For client safety Oxygen as ordered Pain relief; give
pain meds as
ordered
Stimulate Ask client to spit Facilitate excretion Stimulate client to
out airway of residual take a few deep
(shows gag anesthesia breaths every 5-
reflex is back) 10 minutes
Stay Check vital signs Stay with restless
q 15 minutes client
until stable, then
q 30 minutes

b. Recovery Complications and how to react:

Complication Reaction 1 Reaction 2 Reaction 3 Reaction 4

Hypothermia* Apply Increase
 warmed temperature
blankets; of recovery
keep client room
covered
always
Hemorrhage Check Check Check all Check for
dressing for behind client drainage internal
intactness, and on bed tubes: note bleeding:
amount of for blood color and look for
drainage pooling amount of tautness or
drainage distension
at
abdomen
or
incisional
site
Hypotension Give IV Monitor
fluids as blood
ordered pressure

*Note: shivering may result from certain anesthetics

and is not always indicative of hypothermia

c. Provide emotional support and reorientation

d. Notify the family that the surgery is
completed

TYPES OF PAIN

A. Superficial
1. Arises from local tissues
2. Usually related to a nerve ending disturbance
3. Localized; usually described as constant, sharp, tingling or
throbbing
B. Visceral
1. Arises from somatic structures
2. Deep pain; may be dull or aching
C. Referred - Pain felt in another area separate from source of pain
D. Central
1. Caused by injury to central nervous system
2. Very intense pain; burning

Specimens

• Obtain all specimens using gloves and sterile equipment

 • Seal all specimen containers tightly
• Label all specimens with client's name, content and date obtained

X-rays

• Correct views to isolate possible fracture: two view minimum

• Include joints above and below suspected fracture
• Not all fractures show on x-ray; diagnosis relies on clinical evidence
• Especially in children, x-rays of unaffected limb may be needed for comparison

Ostomies

• A stoma has no feeling, so touching it does not hurt client.

• A colostomy may not function for a number of days after surgery.
• Initially ileostomy drainage may be copious and green in color changing to brown
after client resumes normal diet.
• The bowel must be totally healed before attempting irrigation of colostomy.
• Infection, diet or medication may cause spillage between colostomy irrigations.
• Signs and symptoms of bowel perforation include rigid, painful abdomen with
absence of bowel sounds, no output from colostomy except small amount of
blood.
• There will always be some mucus in urinary diversions that involve segments of
bowel, such as ileal loop or continent urinary diversion.

Casts

• A cast may be heavy or impair mobility due to its location

• Analgesics 20-30 minutes before casting reduce pain
• A cast should be snug but not restrict circulation.
• For proper drying, casts must dry from inside out; covering delays drying
• Cast may smell sour but should never smell foul
• Elevation and use of ice reduces swelling
• Report signs of neurovascular impairment immediately

Traction

• Maintain established line of pull and counter traction continuously

• Prevent friction between device and body
• Maintain proper body alignment
• Effective traction correctly aligns affected body parts
• Pain and spasms should be relieved by traction
• Client does not have to keep other body parts immobile

Tracheostomies
 • Clients with new tracheostomy tubes may have bloody secretions for a few days
after the procedure or after a tube change
• Tracheostomy obturator should be attached to head of bed at all times
• Pediatric trach tubes do not usually have an inner cannula
• Children have shorter necks so stoma care may be more difficult
• Yeast infections can form under moist tracheostomy dressings
• The following types of clients may need more frequent trach care

-Tracheal stomatitis

-Pneumonia

-Bronchitis

-Short, fat neck

-Excessive perspiration

• Always have another nurse or family member assist with trach care in case of
accidental dislodgement or extubation
• Because upper airway is not functioning, expect more secretions

Ventilator

• When caring for a client on a ventilator, if an alarm sounds, first, assess the
patient.
• See if the alarm resets or if the cause is obvious.
• If the alarm continues to sound and the client develops distress
1. Disconnect the client from the ventilator
2. Use a manual resuscitation bag
3. Call the respiratory therapist immediately

Suctioning

• Suction no sooner than 2-3 hours after eating

• Be sure to have emesis basin and tissues at hand
• Administer any bronchodilating medications at least 1/2 hour before chest
physiotherapy

Chest tubes

• When caring for a patient with a chest tube, you must know whether the patient
has a leak from the lung. Only when you know there is no leak, may you apply
an occlusive dressing.

Catheterization
 • Intermittent catheterization at home may be a clean, not sterile, procedure

Surgery

• Primary responsibility for obtaining surgical consent rests with the surgeon
• Informed consent cannot be obtained if the client has an altered level of
consciousness, is mentally incompetent, or is under the influence of mind-altering
drugs
• Essential to all pre-op teaching is an explanation of all pre-op and post-op routine
procedures, and a demonstration of post-op exercises.
• Currently most surgery is being performed on an outpatient basis.

Radiation

• Radiation is more effective on local or regional neoplasia while chemotherapy is

more systemic in its effects
• Only certified nurses may administer chemotherapeutic agents
• Ionizing radiation will damage both normal and cancerous cells resulting in side
effects
• Clients receiving external radiation are not radioactive at any time
• Clients receiving internal radiation are not radioactive; the implant or injection is
• If the source is metabolized, the client's secretions and excretions may be
radioactive for a time, based on the half-life of the isotope.

Wounds

• Never touch a wound without wearing sterile gloves

• First post-operative dressing change may be done by physician
• Give analgesic before dressing change so that it peaks during change
• Maintain asepsis
• If drains are present remove dressing one layer at a time to avoid dislodging drain
• Pressure dressings should not be removed
• If dressing must be changed frequently, Montgomery straps will prevent skin
breakdown from frequent tape removal (illustration )
• Wounds out of client's field of vision or reach require help in dressing