Nursing Care and Interventions Flashcards

A practical nurse is caring for a client with chronic kidney disease who is prescribed both erythropoietin and oral ferrous sulfate. The client reports taking their iron tablet with a glass of milk each morning alongside their other medications. Which response by the nurse is most appropriate?

Answer: Instruct the client to take ferrous sulfate on an empty stomach or with orange juice, separated from milk and other medications by at least one hour

Calcium in milk significantly inhibits non-heme iron absorption by competing for the same transport mechanism. Ferrous sulfate should be taken on an empty stomach or with vitamin C (e.g., orange juice), which enhances absorption, and separated from calcium-containing foods, antacids, and other medications by at least one hour. In a CKD patient on erythropoietin, adequate iron stores are critical for the drug to be effective, making proper iron administration especially important.

A nurse is performing a focused neurological assessment on a post-operative client following a transsphenoidal hypophysectomy. Which finding would require the most immediate intervention?

Answer: Clear nasal drainage when the client leans forward

Clear nasal drainage after transsphenoidal hypophysectomy may represent a CSF leak (rhinorrhea), which is a serious post-operative complication indicating a breach in the dura. CSF can be differentiated from mucus by testing for glucose (CSF is glucose-positive) or by the 'halo sign' on a tissue. This finding requires immediate reporting as it carries risk of meningitis and tension pneumocephalus. Although large urine output with low specific gravity suggests diabetes insipidus (also a complication), the clear drainage is the most immediately life-threatening finding requiring urgent assessment to rule out CSF leakage.

A nurse on a medical unit is caring for a client receiving a continuous heparin infusion for deep vein thrombosis. The client's aPTT result comes back at 210 seconds (therapeutic range: 60–100 seconds). The client is currently asymptomatic with stable vital signs. What is the nurse's priority action?

Answer: Hold the heparin infusion and notify the prescriber immediately for dose adjustment

An aPTT of 210 seconds is more than twice the upper therapeutic limit, indicating significant over-anticoagulation and a high bleeding risk even in an asymptomatic client. The nurse must hold the infusion and contact the prescriber immediately for a dose adjustment order. Protamine sulfate is the antidote for heparin reversal but is reserved for life-threatening hemorrhage, not asymptomatic supratherapeutic levels — administering it without a physician order and clear indication would be inappropriate. Independently decreasing the rate or continuing the infusion without notification are unsafe actions that fall outside the PN scope.

A practical nurse is providing care to a client in alcohol withdrawal who was admitted 18 hours ago. The client is now exhibiting new-onset visual hallucinations, diaphoresis, and a heart rate of 118 bpm. The nurse assesses the client's Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score and finds it has risen from 8 to 22. Which action reflects the nurse's best clinical judgment?

Answer: Administer the PRN lorazepam ordered for CIWA-Ar ≥ 8 and immediately notify the physician of the escalating score

A CIWA-Ar score of 22 indicates severe alcohol withdrawal and significant risk for progression to delirium tremens (DTs), which carry a mortality risk. The nurse should administer the ordered PRN benzodiazepine (the cornerstone of symptom-triggered alcohol withdrawal treatment) since the score meets the threshold, and urgently notify the physician because the rapid escalation signals potential deterioration requiring medical reassessment and possible protocol change. Reorientation and comfort measures alone are insufficient at this severity. Restraints are not appropriate as the priority intervention and may worsen agitation. Thiamine administration is important but not the priority action at this moment of acute escalation.

A nurse is caring for a client with heart failure who has been started on spironolactone. The client's most recent lab results show: potassium 5.6 mmol/L, sodium 136 mmol/L, creatinine 148 µmol/L. The client asks if they can take their usual over-the-counter ibuprofen for knee pain. What is the most clinically significant reason the nurse should advise against this?

Answer: Ibuprofen inhibits renal prostaglandins, reduces GFR, and can cause dangerous hyperkalaemia when combined with spironolactone in a client with already-elevated potassium and reduced renal function

While all listed concerns have some validity, the most clinically significant and immediately dangerous interaction in this specific client is the combination of spironolactone (a potassium-sparing diuretic) and ibuprofen in the context of already-elevated potassium (5.6 mmol/L) and reduced renal function (elevated creatinine). NSAIDs inhibit renal prostaglandins, causing afferent arteriole constriction, which reduces GFR and impairs potassium excretion — this can rapidly precipitate life-threatening hyperkalaemia (cardiac arrhythmia risk) and acute kidney injury. This specific triple combination (NSAID + potassium-sparing diuretic + compromised renal function) represents a well-recognized dangerous triad.

A nurse working in a long-term care facility is repositioning a client with a Stage 3 pressure injury to the sacrum. During the turn, the nurse notices the wound now has a foul odor, the surrounding periwound skin is newly indurated and warm, and green-tinged exudate is present. The client has a temperature of 38.9°C. The wound was last assessed two days ago with no signs of infection. What is the nurse's most appropriate sequence of actions?

Answer: Notify the physician of assessment findings, obtain a wound swab for culture and sensitivity before applying any new dressing, and implement infection control precautions

The constellation of findings — purulent green exudate, periwound induration and warmth, malodour, and fever — indicates a wound infection that has likely progressed beyond local infection and may represent spreading soft tissue infection (e.g., cellulitis or early sepsis). The nurse must notify the physician promptly. Critically, a wound culture swab must be obtained BEFORE initiating any new antimicrobial dressing or irrigation, as doing so would contaminate the sample and yield inaccurate culture results, potentially leading to inappropriate antibiotic selection. Infection control precautions (standard plus wound precautions) are appropriate. Applying silver dressings, povidone-iodine, or irrigating before culturing, or deferring to the next wound care visit, all represent unsafe delays or compromise diagnostic accuracy.