Labs & Diagnostics
What are the priority nursing actions when a critical laboratory value is reported?
Verify the result, assess the client for clinical manifestations, implement immediate nursing interventions as appropriate, notify the provider, and document actions taken.
What are potential complications of immobility?
Pressure injuries, Disuse osteoporosis, Constipation, Weight loss or gain, Muscle atrophy, Atelectasis/hypostatic pneumonia, Venous thromboembolism, Urinary system calculi, Depression, Changes in sleep-wake cycle, Sensory deprivation.
A hospitalized older adult has unintentionally lost 12 lb over the past 3 months and reports early satiety. Which assessment findings are most concerning for compromised nutritional status?
Unintentional weight loss, decreased appetite, imbalanced intake and output, low body mass index, integumentary assessment, poor oral intake, and abnormal laboratory values such as low albumin, anemia, iron, glucose, cholesterol, hemoglobin A1C, triglycerides, or prealbumin.
Define tissue perfusion and its nursing significance.
Delivery of oxygenated blood to tissues and organs necessary for cellular metabolism.
What is the nurse’s primary responsibility during the preoperative phase?
Obtaining detailed history, verify and assess for allergies, verify readiness and anxiety level, obtain baseline data, obtain data from labs and diagnostics, ensure informed consent, reduce risk, administer preop meds, ensure NPO status, skin prep, belongings management, prevent hypothermia, IV access, void, ensure safety, complete preop checklist, post-op care education.
A nurse is reviewing morning laboratory results for multiple clients. Which normal reference ranges should the nurse recognize as expected adult values when determining whether further assessment or intervention is required?
Which nursing interventions reduce the risk of immobility complications in a bedbound client?
Passive/Active ROM exercises and ambulation; turn and reposition every 1 to 2 hours as needed; assess skin and keep clean and dry; use pressure-relieving or pressure-reducing devices; adequate nutrition; deep breathing and coughing and IS; hydration; report complications; interdisciplinary collaboration; safe use of devices.
A client with a recent stroke coughs during meals and has difficulty swallowing liquids. What nursing actions are most appropriate to reduce aspiration risk?
Assess swallowing ability, collaborate with speech therapy, position the client upright during meals, provide thickened liquids if prescribed, Have clients tuck their chins when swallowing to help propel food down the esophagus, avoid the use of a straw, monitor for coughing or choking or pocketing food, oral hygiene after meals, limit distractions during eating, and ensure suction equipment is available.
Which assessment findings suggest decreased tissue perfusion?
Tachycardia, decreased urine output, delayed cap refill, cool extremities, hypotension, dyspnea, cool temp, extremity color changes, syncope, dizziness, weak/absent pulses, pain.
A client scheduled for elective surgery appears confused when signing the consent form. What is the nurse’s role in the informed consent process?
Ensure the client is alert and competent, clarify the procedure and risks as needed (no new info), and notify the provider if the client cannot give informed consent.
A UAP reports abnormal vital signs on a client. BP 172/88, HR 98, RR 18, temp 99.4F, and pulse ox of 90% on room air. What is the nurse’s next best action?
The nurse must promptly assess the client and validate the findings before determining and implementing further interventions.
A client with a hip replacement is using an abduction pillow and foot boots. Which interventions maintain alignment and prevent complications?
Keep the pillow between the legs at all times, ensure neutral hip abduction, monitor skin for pressure injuries, adjust foot boots to prevent heel breakdown, and educate the client on safe turning and movement techniques.
A hospitalized client has poor appetite, unintended weight loss, and fatigue. The nurse identifies the client as malnourished. Which nursing interventions are most appropriate to improve nutritional intake and promote recovery?
Assess/address underlying causes; small, frequent, nutrient-dense meals; high-protein supplements between meals; comfortable position with tray in reach; clean eating environment; restrict excessive fluids with meals; control pain; oral hygiene prior to meals; collaborate with nutritionist.
What nursing intervention best promotes venous return?
Early ambulation, SCDs, leg exercises, administration of medications for prevention of clots, leg positioning, TED stockings, leg exercises (ROM; ankle pumps, foot circles, and knee flexion), hydration, patient repositioning.
What are potential complications that can occur in the postoperative period?
Airway obstruction, hypoxia, hypovolemic shock, paralytic ileus, pneumonia, DVT, wound dehiscence/evisceration.
A client develops shortness of breath and facial flushing shortly after receiving IV contrast for a CT scan. What is the nurse’s priority response?
Stop the infusion if ongoing, assess airway and oxygenation, administer oxygen, and notify the provider immediately.
A client is being discharged with a cane for left leg weakness. Which instruction should the nurse include?
Hold the cane on the stronger side, keep two points of support on the floor, advance the cane 15–25 cm (6–10 in), then move the weaker leg forward, and finally advance the stronger leg past the cane.
A hospitalized older adult has experienced unintentional weight loss, becomes fatigued while eating, and is observed pocketing food in the cheeks. The client can swallow liquids without coughing but has difficulty chewing solid foods. Which diet is most appropriate, and what nursing interventions should accompany this choice?
Initiate a puréed diet and implement interventions such as assisting with meals, offering small frequent feedings, monitoring intake trends, providing nutrient-dense foods, and collaborating with dietary services for supplementation.
A 62-year-old client with hypertension and a sedentary lifestyle is seen in the clinic for a routine check-up. Which nursing interventions best support perfusion and prevent decreased perfusion?
Educate the client about regular aerobic exercise, a heart-healthy diet (low sodium, low saturated fat), smoking cessation, blood pressure monitoring, and stress reduction strategies.
A 58-year-old client is about to receive moderate sedation for a surgical procedure. As the nurse preparing the client, which of the following actions are essential to ensure safety and optimal outcomes?
Verify that the client has signed a consent form. Ensure the client voids prior to receiving sedation. Place the bed in the low position and raise the side rails. Monitor airway, oxygen saturation, and vital signs continuously. Monitor cardiac status, including rhythm, heart rate, and blood pressure. Assess laboratory values as indicated (ABGs, CBC, electrolytes). Monitor temperature. Apply safety belts once the client is positioned on the surgical table. Monitor drains, tubes, catheters, and IV access throughout anesthesia. Assess level of sedation and anesthetic effects. Implement interventions for hypotension (lower head of bed, administer IV fluids). Notify the surgeon and anesthesiologist of any abnormalities.
Before a client undergoes an MRI, what safety checks must the nurse complete to prevent serious injury or harm?
The nurse must verify the presence of any ferromagnetic implants or devices (e.g., pacemakers, aneurysm clips, cochlear implants), remove all metal objects, assess for contrast allergies and renal function if contrast is ordered, screen for pregnancy when applicable, and evaluate the client for claustrophobia or inability to remain still.
Rationale: MRI uses powerful magnetic fields that can dislodge metal objects or malfunction implanted devices, causing life-threatening injury. Nursing responsibility includes comprehensive pre-procedure screening, patient education, and ensuring environmental safety. Failure to identify contraindications can result in burns, device displacement, or cardiac complications.
A client is in skeletal traction following a femur fracture. What nursing interventions maintain proper traction and prevent complications?
Ensure weights hang freely, maintain alignment of the extremity and body, monitor neurovascular status (distal pulses, capillary refill, color, sensation, movement) every 1–2 hours, assess for signs of compartment syndrome, and notify the provider of any abnormalities.
A client is receiving total parenteral nutrition (TPN) via a central line. Which nursing assessments and interventions are priorities to prevent complications?
Monitor blood glucose levels, assess for signs of infection, verify correct solution and infusion rate, maintain strict aseptic technique during line care, monitor electrolytes and fluid balance, and assess for signs of metabolic complications.
A client with chronic heart failure presents with shortness of breath, edema, and weight gain of 5 pounds in 2 days. Labs show BNP 1200 pg/mL and potassium 5.1 mEq/L. What is the nurse’s priority plan?
Assess respiratory and cardiovascular status, initiate interventions to reduce fluid overload (e.g., diuretics as prescribed), monitor electrolytes closely, and educate the client on daily weight and symptom management.
A client is 6 hours postoperative following abdominal surgery. Which nursing interventions are highest priority to prevent complications?
Monitor vital signs and oxygen saturation, physical assessment depending on surgery, encourage deep breathing and coughing, incentive spirometer, assess pain and provide analgesia, promote early ambulation, reposition every 2 hours, monitor for bleeding, oral hygiene, advance diet as prescribed (keep NPO until return of gag reflex and peristalsis), pain management, apply SCDs or stockings, monitor wounds and incisions (wound care as applicable), splinting, manage drains, and maintain fluid and electrolyte balance.