NURS 131 Exam study

jasmine's version from 2016-04-20 05:00

Section 1

Question Answer
You are assessing a long-term care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? The bladder is palpable above the symphysis pubis and the client is restless. Rationale: A palpable bladder and restlessness are indicators of bladder distention, which would require action (such as insertion of a catheter) in order to empty the bladder. The other data would be consistent with the client’s diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is needed. Focus: Prioritization
While performing a breast examination on a 22 year old client, you obtain the following data. Which finding is of most concern? An irregularly shaped, non-tender lump is palpable in the left breast. Rationale: Irregularly shaped and non-tender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound. The other information is not unusual and does not indicate the need for immediate action. Focus: Prioritization
After undergoing a modified radical mastectomy, a client is transferred to the post-anesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/LVN? Monitoring the client’s dressing for any signs of bleeding. Rational: An LPN/LVN working in a PACU would be expected to check dressings for bleeding and alert RN staff members if bleeding occurred. The other tasks are more appropriate for nursing staff with RN level education and licensure.
You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? Elevating the client’s arm on two pillows to promote lymphatic drainage. Rational: Positioning the client’s arm is a task that a nursing assistant who works on a surgical unit would be educated to do. Client teaching and assessment are RN level skills. Elastic bandages are not usually used in the immediate post-operative period because they inhibit collateral lymphatic drainage. Focus: Delegation
You obtain the following assessment data about your client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? The client reports painful bladder spasms. Rational: The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 – 50 mL of saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care. Focus: Prioritization
A 67 year old client with BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client? “You should avoid sitting up or standing up too quickly.” Rational: Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change position slowly. The other information is also accurate and may be included in client teaching, but is not as important as decreasing the risk for falls. Focus: Prioritization
You are caring for a client who has just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? Catheter that is draining deep red blood. Rational: Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately. The other assessment data also indicate a need for nursing action, but not as urgently. Focus: Prioritization

Section 2

Question Answer
2 Phases of the ovarian cycle Follicle and Luteal
Follicle Phase (days 1-14) Follicle matures and ovulation occurs
Luteal Phase (days 15-28) Begins when the ovum leaves the follicle, and the corpus luteum develops from the ruptured follicle
Four phases of menstrual cycle Menstrual, proliferation, secretory, and ischemic (if plantation does not occur)
Menstrual Occurs during the menstrual phase with shedding of some, but not all, endometrial cells
Proliferation The endometrial cells enlarge and become twisted under the influence of estrogen, and the endometrium thickens
Secretory Progesterone causes marked swelling and the amount of tissue glycogen increases. Vascularity of the entire uterus increases greatly, providing a nourishing bed for implantation
Ischemic (if implantation does not occur) Corpus luteum begins to degenerated Estrogen and progesterone levels fall. This phase is characterized by the escape of blood into the stromal cells of the endometrium/myometrium
Microbiome Full collection of microbes that naturally exist within the body; The microorganisms in a particular environment (including the body or a part of the body)
Alterations or disruptions in core microbiome associated with chronic illness Crohns disease; increased susceptibility to infection; allergy; Necrotising Enterocolitis (NEC) (vomiting green bile)
Necrotising Enterocolitis (NEC)An inflammation of the bowel (intestines) that may damage the bowel to a variable extent. It usually causes a temporary intolerance of milk feeds, yet at its worse the bowel may be so damaged that parts of it actually die. NEC may affect just a small part of the bowel or, on occasions, the whole bowel may be affected. It has a variable course ranging from feed intolerance and abdominal distension (swelling) to a sudden collapse of a baby who had previously been relatively well
Microbiome beneficial effect for the host Nutrient metabolism; Tissue development; Resistance to colonization with pathogens; Maintenance of intestinal homeostasis; Immunological activation and protection of GI integrity
Core microbiome established Soon after birth
Core microbiome of breastfeeding infant similar to Core microbiome of lactating mother
Components of breastmilk supporting establishment of microbiome Probiotics and prebiotics
Specific proteins in breast milk Lactoferrin, Secretory IgA, Lysozyme, Bifidus factor
Lactoferrin Inhibits the growth of iron-dependent bacteria in the GI tract; this inhibits certain organisms such as coliforms and yeast that require iron
Secretory IgA Works to protect the infant from viruses and bacteria, specifically those that the baby, mom, and family are exposed to; It also helps to protect against E. coli and possibly allergies; Other immunoglobulins, including IgG and IgM, in breast milk also help protect against bacterial and viral infections; Eating fish can help increase the amount of these proteins in breastmilk
Lysozyme An enzyme that protects the infant against E. coli and Salmonella; It also promotes the growth of healthy intestinal flora and has anti-inflammatory functions
Bifidus factor Supports the growth of lactobacillus; Lactobacillus is a beneficial bacteria that protects the baby against harmful bacteria by creating an acidic environment where it cannot survive

Section 3

Question Answer
Risks for infants formula feed Increased otitis media, allergies, asthma, lower respiratory infections, obesity, sudden infant death syndrome, diabetes, diarrhea, higher adult blood pressure, immune system problems, cancers such as lymphoma, Crohn’s disease, juvenile arthritis and on and on and on
Maternal benefits of breast feeding Decreased anemia, increased involution of uterus, increased weight loss, decreased incidence of pre-menopausal breast and uterine cancer, decreased osteoporosis (hormones increase Calcium absorption and limit the amount excreted)
Colostrum contents Low in fat, high in proteins and carbohydrates, and very easy to digest; High concentration of antibodies, especially IgA antibody that helps protect the lungs, throat, and intestines
What does colostrum help “seal?” The permeable newborn intestines to prevent harmful substances from penetrating the gut
Colostrum has a laxative effect that helps what?The baby to pass first bowel movements and prevent newborn jaundice
All mothers have colostrum. What must stop? Telling mothers they do not have any milk, as this is a fallacy (mistaken belief) and is not practicing evidence-based practice
The importance of breast feeding in the first hour Failure to initiate breast feeding within the first hours of life was one of the strongest predictors of early termination of breast feeding at two months
During the first 30-60 minutes of the newborn’s life Newborn’s have the natural ability to latch and suck effectively; Newborn’s typically are alert and rooting; and feeding in the first hour imprints the newborn with unique sucking movements
Remember in latching It must be comfortable for the mother; If she says it hurts or is painful, then you must investigate and figure out why
Newborn latching Nose to nipple; head tipped back; tongue down and forward; mouth open wide; scoop on gently yet quickly
During feedings, do not time newborn per side This will not allow the newborn to regulate milk flow and intake requirements (e.g., every 1-3 hours per 24 hours; 1st side dinner, 2nd side dessert)
Remember! Supply and demand (there may not be enough milk available due to growth spurts)
Night time feedings Stimulates milk production during the time period when their hormonal levels are at their highest, which is typically between 0200 and 1000
Breast feed problems in late pre-term newborn (34-37 weeks) Primary problems: hyperbilirubinemia and breast feeding
Breast feed problems in pre-mature newborn Mother makes specific milk for the preemie!! Important to get pumping and establish the milk supply
Assessment of painful and/or cracked nipples Look at the nipple as it comes out of the baby’s mouth-pinched, misshapen, deformed?; Assess newborn’s mouth-tongue tied? Instruct in correct latching and positioning; Allow the newborn to explore and latch on own (baby’s resist if physically pushed on)
When decreased volume of milk may occur On demand feedings (growth spurt): No supplementation unless medically necessary; Breast massage before and during feedings; Possibly use breast pump after feedings for about 5 minutes for added stimulation
Possible issues with maternal breast feeding Breast physiology; Augmentations (silicon in front of or behind breast muscle? If in front of, interfering with mammary glands?); Reductions; History of sexual abuse; Pre-maturity of self and interventions that interfered with breast tissue development; Transgender-Female to male (FTM)
Possible issues with newborn breast feeding Congenital anomalies such as cleft lip/palate; Pre-maturity; Illness; Tongue tie (ankyloglossia) anteriorly and/or posteriorly
Ten steps to successful breast feeding A written breast feeding policy; Train staff to implement this policy; Inform all pregnant women of the benefits of breast feeding; Help mothers initiate breast feeding within the first half hour; Help mothers maintain lactation if separated; Provide NO food or drink other than breast milk unless medically indicated; Encourage rooming in; Encourage breast feeding on demand; Provide NO artificial teats or pacifiers; Promote follow up breast feeding services and support post-discharge