Nursing Care and Interventions Flashcards

A practical nurse is caring for a client with chronic kidney disease who is receiving a continuous heparin infusion. The client's aPTT comes back at 142 seconds (therapeutic range 60–100 seconds). The client is alert and has no signs of active bleeding. What is the PRIORITY nursing action?

Answer: Hold the heparin infusion and notify the physician immediately

An aPTT of 142 seconds is significantly above the therapeutic range, indicating a dangerously supratherapeutic anticoagulation level. Even without active bleeding, the risk of hemorrhage is high. The nurse must hold the infusion and notify the physician immediately so a dosage adjustment order can be obtained. Protamine sulfate is a reversal agent that requires a physician's order and is not a standing nursing intervention. Independently adjusting the rate or simply rechecking without notifying the physician is outside the PN's scope of practice for this situation.

A nurse is caring for a postoperative client who had a thyroidectomy 8 hours ago. The client reports tingling around the mouth and fingertips. Chvostek's sign is positive. Which intervention is MOST appropriate as the immediate priority?

Answer: Prepare to administer IV calcium gluconate as ordered

Perioral tingling, fingertip tingling, and a positive Chvostek's sign are classic indicators of hypocalcemia, which can occur after thyroidectomy due to inadvertent damage or removal of the parathyroid glands. Hypocalcemia can progress rapidly to laryngospasm and tetany, making IV calcium gluconate the priority intervention. Oral calcium intake is far too slow for an acute symptomatic presentation. Oxygen and positioning address airway management but do not correct the underlying electrolyte deficiency causing the symptoms.

A practical nurse is assigned to a client receiving total parenteral nutrition (TPN) via a central venous catheter. When preparing to hang a new bag, the nurse notices the TPN solution appears cloudy with visible particulate matter. The pharmacy delivered it 30 minutes ago. What should the nurse do FIRST?

Answer: Do not hang the solution; return it to the pharmacy and document the finding

TPN solution should be clear; cloudiness or visible particulates indicates precipitation, contamination, or incompatibility between components. This solution must never be administered. Filters may capture some particles but do not make a compromised solution safe, and agitating will not re-dissolve incompatible precipitates. The correct action is to withhold the solution, return it to the pharmacy, and document — ensuring the client receives a safe replacement bag without delay.

A nurse is caring for a client in alcohol withdrawal who is on a CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) protocol. The client's score is 18. The client is oriented but is experiencing moderate diaphoresis, tremors, and anxiety. Which medication would the nurse MOST likely administer based on this assessment?

Answer: Lorazepam as per the symptom-triggered protocol

A CIWA-Ar score of 18 indicates moderate-to-severe alcohol withdrawal warranting pharmacological intervention. Benzodiazepines such as lorazepam are the first-line agents in symptom-triggered withdrawal protocols because they cross-react with alcohol at the GABA receptor, suppressing CNS hyperexcitability and reducing the risk of seizures and delirium tremens. Haloperidol does not prevent seizures and may lower the seizure threshold. Disulfiram is an aversion agent used in maintenance treatment, not acute withdrawal. Naltrexone addresses opioid dependence and alcohol craving reduction, not acute withdrawal symptoms.

A practical nurse is preparing a client for discharge after a transurethral resection of the prostate (TURP). The client's urine has been continuously irrigated and is now light pink. During discharge teaching, the client asks when he should call his physician. Which statement by the nurse is MOST clinically appropriate?

Answer: "Call your physician if your urine becomes bright red, you pass clots, or you are unable to urinate."

After TURP, light pink urine and some spotting for several weeks is expected as the surgical site heals. However, bright red urine, passage of clots, or inability to void are signs of significant hemorrhage or obstruction requiring immediate medical attention. Telling the client never to expect blood is inaccurate and may cause unnecessary alarm over normal healing. A fever threshold of 40°C is dangerously delayed — signs of infection (fever >38.5°C, dysuria, foul odor) should prompt contact. Home bladder irrigation is not a standard post-discharge instruction for this procedure.

A nurse is caring for a client with systemic lupus erythematosus (SLE) who is admitted for a disease flare. The client is on hydroxychloroquine and high-dose prednisone. The client develops sudden onset dyspnea, pleuritic chest pain, and oxygen saturation of 91% on room air. The nurse suspects pulmonary embolism. After calling the physician, what is the MOST appropriate immediate nursing intervention?

Answer: Apply supplemental oxygen and position the client in high Fowler's position

The immediate priority for suspected PE with hypoxemia is to correct hypoxia by applying supplemental oxygen and optimizing respiratory mechanics with high Fowler's positioning, which reduces diaphragm pressure and improves tidal volume. While preparing for anticoagulation (labs and IV access) is important and will follow, correcting the acute hypoxia takes precedence as the first nursing action. Administering prednisone does not address a thromboembolic event. Trendelenburg positioning is contraindicated in PE because it increases venous return to an already-compromised right ventricle and worsens dyspnea.