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saunders pain med surg 1 ex 2

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What vital sign finding in the postoperative client on demand-dose hydromorphone via a PCA pump would be most concerning for the nurse?

SpO2 of 93% on 3 liters of oxygen via nasal cannula

What is the most appropriate action for the nurse caring for the drowsy postoperative client on demand-dose hydromorphone via a PCA pump?

Attempt to arouse the client

What is the most likely cause for the hemoglobin level of 10.8 g/dL in the client's history?

Dehydration

Why would a nurse place a client with peptic ulcer disease and prior upper gastrointestinal bleeding on bleeding precautions?

<p>Report an abnormally low platelet count</p> Signup and view all the answers

If a client with peptic ulcer disease and previous upper gastrointestinal bleeding has a platelet count of 300,000 mm3, what is the expected nurse's action?

<p>Report the abnormally high count</p> Signup and view all the answers

In a client on demand-dose hydromorphone via PCA pump, what is the most concerning sign of respiratory depression?

<p>Respiratory rate of 11 breaths per minute</p> Signup and view all the answers

What does the glycosylated hemoglobin A1c test measure?

<p>The amount of glucose attached to red blood cells</p> Signup and view all the answers

How long do red blood cells typically live for?

<p>120 days</p> Signup and view all the answers

What does an elevated glycosylated hemoglobin A1c level indicate?

<p>Hyperglycemia</p> Signup and view all the answers

What is the normal reference range for glycosylated hemoglobin A1c?

<p>Less than 5.7%</p> Signup and view all the answers

What health problem is the glycosylated hemoglobin A1c test particularly useful in identifying?

<p>Hyperglycemia</p> Signup and view all the answers

What is the main concern when a client is taking ibuprofen concurrently with a calcium channel blocker?

<p>Potential toxicity</p> Signup and view all the answers

Why should ibuprofen not be combined with anticoagulants?

<p>May lead to toxicity</p> Signup and view all the answers

Which adverse effect may occur if ibuprofen is taken with antidiabetic agents?

<p>Hypoglycemia</p> Signup and view all the answers

Why should NSAIDs not be combined with calcium channel blockers?

<p>Possible toxicity</p> Signup and view all the answers

What should be considered when combining ibuprofen with antilipemic medications?

<p>Potential for gastrointestinal bleeding</p> Signup and view all the answers

Which action is recommended when a client is taking ibuprofen and a calcium channel blocker together?

<p>Avoid this combination due to the risk of toxicity</p> Signup and view all the answers

What is the primary concern with opioid analgesics according to the text?

<p>Respiratory depression and hypotension</p> Signup and view all the answers

What would the nurse suspect based on assessment findings in case of opioid overdose?

<p>Opioid overdose</p> Signup and view all the answers

Which laboratory test monitors the effects of heparin therapy?

<p>aPTT</p> Signup and view all the answers

In the context provided, what actions would not be implemented until PT and INR levels were known?

<p>Administering an antidote</p> Signup and view all the answers

For a client who has taken an excessive dose of warfarin, what would be the focus according to the text?

<p>Monitoring for cardiac dysrhythmias</p> Signup and view all the answers

What would be the first action that a nurse would take in case of suspected opioid overdose?

<p>Attempt to arouse the client</p> Signup and view all the answers

What is the platelet count of 300,000 mm3 (300 × 10^9/L) considered to be?

<p>Normal</p> Signup and view all the answers

Based on the text, what precautions are NOT needed for a platelet count of 300,000 mm3 (300 × 10^9/L)?

<p>Bleeding precautions</p> Signup and view all the answers

What is the appropriate nursing action for a platelet count of 300,000 mm3 (300 × 10^9/L)?

<p>Encouraging vigorous exercise</p> Signup and view all the answers

What is the level of cognitive ability required when interpreting a platelet count of 300,000 mm3 (300 × 10^9/L)?

<p>Application</p> Signup and view all the answers

Which nursing process is primarily involved in managing a patient with a platelet count of 300,000 mm3 (300 × 10^9/L)?

<p>Implementation</p> Signup and view all the answers

What does a BUN level of 3 mg/dL (1.08 mmol/L) indicate?

<p>Fluid volume overload</p> Signup and view all the answers

Which temperature measurement method should be avoided for a client with nasal congestion?

<p>Oral temperature</p> Signup and view all the answers

Why should other less invasive temperature measurement methods be preferred over rectal temperature?

<p>Rectal temperatures are uncomfortable for the client</p> Signup and view all the answers

In a client who has undergone nasal surgery, which temperature measurement method is appropriate?

<p>Rectal temperature</p> Signup and view all the answers

What is the significance of avoiding oral temperature measurement in clients with nasal congestion?

<p>Oral temperature may not reflect core body temperature accurately</p> Signup and view all the answers

When other methods are unavailable, what is an acceptable alternative to measuring body temperature?

<p>Rectal temperature</p> Signup and view all the answers

What is the normal range for aPTT?

<p>30-40 seconds</p> Signup and view all the answers

What is the therapeutic range of aPTT when on heparin therapy?

<p>45-60 seconds</p> Signup and view all the answers

Why should nasal congestion be avoided when taking an oral temperature?

<p>Affects the accuracy of the reading</p> Signup and view all the answers

In what scenario would measuring temperature on the neck behind the ear be acceptable?

<p>If electronic equipment is available and the client is diaphoretic</p> Signup and view all the answers

What action should be taken if a client has a platelet count of 300,000 mm3?

<p>Monitor closely for signs of infection</p> Signup and view all the answers

What is a critical reason for avoiding axillary temperature measurement?

<p>It can be influenced by outside factors like drinking coffee</p> Signup and view all the answers

What WBC count range indicates a decrease in the number of circulating WBCs and may lead to the implementation of neutropenic precautions?

<p>2000 to 3000 mm3</p> Signup and view all the answers

Which of the following is a critical value that may trigger the implementation of neutropenic precautions in a client?

<p>2500 mm3</p> Signup and view all the answers

What laboratory values would the nurse plan to assess in a client to determine anticoagulation status and risk for bleeding?

<p>PT and INR levels</p> Signup and view all the answers

What cognitive skill is primarily involved in determining when to implement neutropenic precautions?

<p>Critical Thinking</p> Signup and view all the answers

What is the primary concern when the nurse plans to draw a sample for PT and INR levels in a client?

<p>Anticoagulation Status</p> Signup and view all the answers

Which concept is most relevant when planning to draw lab samples for PT and INR levels in a client?

<p>Safety Precautions</p> Signup and view all the answers

Which of the following laboratory values are abnormal based on the information provided?

<p>White blood cell count: low</p> Signup and view all the answers

What is the significance of a low segmented neutrophil level in a patient's laboratory results?

<p>Increased risk of infection</p> Signup and view all the answers

Why is it important for healthcare providers to know the normal values of various blood studies mentioned in the text?

<p>To interpret laboratory results accurately</p> Signup and view all the answers

What action should be taken regarding a patient's medications if they are on anticoagulants and present with low platelet levels?

<p>Do not combine NSAIDs and anticoagulants</p> Signup and view all the answers

Which medication combination should be avoided to prevent hypoglycemia in a patient taking ibuprofen?

<p>Antidiabetic agents and NSAIDs</p> Signup and view all the answers

How does the presence of high sodium levels impact a patient's health status?

<p>Leads to hypernatremia</p> Signup and view all the answers

What is the rationale for not placing a client with a platelet count of 300,000 mm3 on bleeding precautions?

<p>The client's platelet count is within the normal range.</p> Signup and view all the answers

What should a nurse do if a client has a platelet count of 300,000 mm3 (300 × 10^9/L) based on the text?

<p>Monitor the client for signs of bleeding or bruising.</p> Signup and view all the answers

What nursing action would be appropriate for a client with a platelet count of 300,000 mm3 (300 × 10^9/L)?

<p>Monitor for signs of infection.</p> Signup and view all the answers

Which statement reflects the correct understanding of a platelet count of 300,000 mm3?

<p>This count is within the normal range for platelets.</p> Signup and view all the answers

What precaution is NOT necessary for a client with a platelet count of 300,000 mm3?

<p>Taking anticoagulant medications.</p> Signup and view all the answers

Study Notes

Laboratory Tests

  • A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count and is also not low, therefore, bleeding precautions are not needed.
  • Glycosylated hemoglobin A1c measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose, and is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways.
  • The normal reference range for glycosylated hemoglobin A1c is less than 5.7%, and elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.
  • The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 183 mg/dL (10.1 mmol/L).

Nursing Process

  • When planning care, the nurse should focus on the subject of the question and recall the normal range for the laboratory test to direct them to the correct option.
  • When implementing care, the nurse should prioritize the client's needs, such as arousing the client suspected of opioid overdose, and then reassessing the vital signs.

Vital Signs

  • When measuring temperature, the nurse should avoid taking an oral temperature if the client has nasal congestion, and instead use other methods such as rectal or axillary temperature measurement.

Medication Administration

  • NSAIDs can amplify the effects of anticoagulants, and therefore, should not be taken together.
  • Hypoglycemia may result if the client taking ibuprofen is concurrently taking an oral antidiabetic agent, and these medications should not be combined.

Client Education

  • The nurse should educate clients on the prevention of hyperglycemic episodes and provide teaching related to anticoagulation therapy.

Health Problems

  • Clients with peptic ulcer disease and a history of upper gastrointestinal bleeding may have a normal platelet count, but still require monitoring and care.
  • Clients with diabetes may have elevated glycosylated hemoglobin A1c levels, indicating a need for further education and prevention of hyperglycemic episodes.

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