Procedures and Care - NCLEX-PN

When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.

The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below in a non-diabetic patient. The symptoms of hypoglycemia include altered consciousness, tremors, weakness, vertigo, headaches, heart palpitations, and a bounding pulse.

A temperature of is not considered abnormal as it may reflect a normal variation in body temperature.

His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.

It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.

Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.

Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.

The four main categories of shock are as follows:

• Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
• Hypovolemic: Due to loss of fluids or hemorrhage.
• Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
• Anaphylactic: Systemic inflammatory response to an allergen.

Varicella requires airborne precautions. Staff caring for patients with varicella should be immune. One's immunity to varicella can be confirmed by a blood test.

Standard precautions should be utilized in the care of every patient. Hand hygiene before and after patient contact is always required. Clean, functioning, equipment should always be available. The use of personal protective gear when there is potential to blood or bodily fluid exposure is critical. This includes the proper disposal of soiled materials such as linens. However, it is not necessary for patients to be housed in private rooms unless they are affected by an infectious disease. If private rooms for infectious individuals are unavailable, it is acceptable to place patients in cohorts of the same infectious disease.

The normal range for hemoglobin in an adult female is . Hemoglobin levels above that range may be indicative of chronic low blood oxygen, while lower levels of hemoglobin are seen in anemia.

The normal range for hemoglobin levels in an adult male is . Hemoglobin levels above that range may be indicative of chronic low blood oxygen, while lower levels of hemoglobin are seen in anemia.

When percussing the seventh intercostal space along the right midclavicular line, you should expect to hear a dull note, as this is directly over the solid mass of the liver.

The border of the liver can be found by percussing in a descending line along the intercostal spaces of the right midclavicular line, starting at the clavicle. The superior border of the liver can be measured at the point where percussion transforms from resonant or hyperresonant (indicating the air-filled lung) to dull (indicating the solid mass of the liver).

A healthy and normal abdominal aorta will measure between 2.5-3cm in diameter. An abdominal aorta over 3cm and under 5cm in diameter is considered to be enlarged, and surgery to prevent abdominal aortic aneurism is generally performed on abdominal aortas that surpass 5cm in diameter in females or 5.5cm in diameter in males.

A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.

Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.

In this case, the patient is able to move their biceps brachii against gravity, but they are unable to move against gentle resistance by the examiner. This means the muscle strength should be graded at .

The muscle strength grade is as follows:

: no contraction

: muscle contraction, but no movement

: movement with gravity, but not against gravity

: movement against gravity, but not against resistance

: movement against mild resistance by the examiner

: normal muscle strength

Normal levels for sodium are between . Anything below (hyponatremia) or above (hypernatremia) this is considered abnormal and should be evaluated further.

The range for normal potassium levels in blood is . Anything above that (hyperkalemia) or below that range (hypokalemia) is considered abnormal.

The normal adult reference range for blood calcium levels is .

An adult male hematocrit is considered normal when between . Anything below this may indicate anemia, elevated white blood cell count, or blood loss, while numbers above this may indicate dehydration, chronic oxygen deficiency, or a condition of excess red blood cell production (such as polycythemia vera).

The normal reference range for an adult female hematocrit is . Anything below this may indicate anemia, elevated white blood cell count, or blood loss, while numbers above this may indicate dehydration, chronic oxygen deficiency, or a condition of excess red blood cell production (such as polycythemia vera).

A normal erythrocyte sedimentation rate should be below . Anything above this indicates some sort of inflammatory process.

All of his vitals and blood work are within normal range except his cholesterol. Normally, cholesterol is considered within normal range if it is under , but in the case of patients with past history of cardiac event or stroke, cholesterol should be maintained at under .