NR 452 capstonerem10,Questions and Answers,100% CORRECT

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NR 452 capstonerem10,Questions and Answers A client is receiving external radiation therapy. Identify three (3) examples of potential adverse reactions to this therapy that can occur to the skin and ... mucous membranes. Suggested Medical Surgical Learning Activity: Radiation Therapy • Skin: blanching, erythema, desquamation, sloughing, hemorrhage • Mouth: mucositis, xerostomia(dry mouth) • Neck: difficulty swallowing • Abdomen: Gastroenteritis The nurse is caring for a client with osteoporosis. Discuss general nursing care required for this client including fall prevention techniques. (Review the Fundamentals Review Module) Suggested Fundamentals Learning Activity: Home Safety • For fall prevention make sure to discard of rugs and loose carpet, place electrical cords behind furniture or close to walls, provide aids as needed, use nonskid mats in the shower, place grab bars near toilet and shower, place shower chair in the shower and provide bedside commode as needed, ensure adequate lighting. • Help assess the home environment for safety hazards if possible • Instruct client on adequate values of vitamin D, calcium, protein, magnesium and other trace minerals • Encourage weight bearing exercises A nurse is providing education to a client who has multiple risk factors for coronary artery disease (CAD). What information regarding reducing CAD risk factors should the nurse include? Suggested Medsurg Learning Activity: Coronary Artery Disease (CAD) • Maintain an exercise routine to remain physically active • Have cholesterol and blood pressure checked on a regular basis • Consume a diet low in saturated fats and sodium • Promote smoking cessation A nurse is providing education to a client at risk for osteoporosis. What information for prevention of osteoporosis should the nurse include in this education? Suggested Medsurg Learning Activity: Osteoarthritis, Osteoporosis, Rheumatoid Arthritis • Ensure the client has a diet with adequate vitamin D and calcium • Discourage carbonated beverages • Discuss pros and cons of hormone replacement therapy • Encourage weight bearing exercises A client with hip osteoarthritis will undergo a total hip arthroplasty. What are two (2) postoperative complications following total hip arthroplasty? Suggested Medical Surgical Learning Activity: Arthoplasty • Monitor for evidence of incisional infection: fever, increased redness, swelling, purulent drainaige • Monitor for DVT, which can lead to pulmonary embolism, anemia, infection, and neurovascular compromise. A nurse is caring for a client in Buck’s traction. What is the purpose of this type of traction? Suggested Medsurg Learning activity: Immobilization Devices • The goal of traction is to prevent soft tissue injuries, realign bone fragments, decrease muscle spasms and pain, and correct or prevent further deformities A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion reaction is suspected? • Stop or slow the infusion • Monitor vital signs and fluid status • Administer epinephrine, oxygen or CPR if needed • Initiate an infusion of 0.9% sodium chloride using new tubing While assessing a patient two hours after a transurethral prostatectomy (TURP), the nurse notes the catheter drainage is bright red in color and contains many clots. Name the priority nursing intervention. Suggested Medical Surgical Learning Activity: Male Reproductive Disorders • Increase the rate of CBI • Increase traction on the catheter A nurse is caring for a client with a burn injury who has been prescribed hydrotherapy. How is hydrotherapy instituted and what actions should the nurse take during this therapy? Suggested Medical Surgical Learning Activity: Burns • Assist the client into a warm tub of water or use warm running water as if to shower to cleanse the wound • Use mild soap or detergent to wash burns gently, then rinse with room-temperature water • Encourage the client to exercise his joints during the hydrotherapy treatement A nurse is caring for a client with heat stroke. Identify three (3) manifestations of heat stroke. Provide immediate nursing management for each identified manifestation of heat stroke. • Heat stroke will have hot skin, high body temp often over 106 • Classic heat stroke patient will have dry skin, hypotension, fever and coma • Exertional heat stroke will usually be sweating, will have heat stroke confusion, bizarre behavior and collapse • Treatment will include cooling patient rapidly, monitor airway and circulation, observe seizure precaution List three (3) client teaching points following permanent pacemaker insertion.Suggested Medical Surgical Learning Activity: ECG Interpretation • Carry a pacemaker identification card at all times • Wear sling when out of bed and do not raise arm above shoulder for 1 to 2 weeks • Take pulse daily at the same time. Notify the provider if heart rate is less than pacemaker rate The nurse is performing a physical assessment on a client who recently had a hip arthroplasty. List five (5) physical assessment findings associated with the development of a pulmonary embolism.Suggested Medical Surgical Learning Activity: Pulmonary Embolism • Tachycardia • Tachypnea • Weak, rapid pulse • Hypotension • Restlessness [Show More]

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