Unexpected Responses to Therapies: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of unexpected responses to therapies in order to:

• Assess the client for unexpected adverse response to therapy (e.g., increased intracranial pressure, hemorrhage)
• Recognize signs and symptoms of complications and intervene appropriately when providing client care
• Promote recovery of the client from unexpected response to therapy (e.g., urinary tract infection)

Assessing the Client for Unexpected Adverse Responses to Therapy

Virtually all treatments, therapies, interventions and procedures have potential risks and complications. Some of the causes of these responses are accidental and inadvertent and others are those that occur as a normal and/or relatively commonly occurring, but undesirable, response to treatments, therapies, interventions and procedures such as an adverse response and reaction to a medication.

Some of the accidental and inadvertent unexpected responses to therapy and procedures can include the accidental and inadvertent:

• Maternal trauma, lacerations, pelvic floor damage, bleeding and an inadvertent extension of the episiotomy to the anus when a forceps delivery of a new born is done

• Tube leakage, improper placement and the dislodgment of a nasogastric or another gastric tube

• Pneumothorax, hemothorax or hydrothorax when a total parenteral nutrition (TPN) catheter perforates the vein and fluid enters the pleural space during insertion

• The punctures of major vessels can occur during a number of surgical interventions, invasive procedures and some invasive diagnostic tests such as the puncture of the descending aorta during a major abdominal surgical procedure, during the placement of an epidural catheter for anesthesia and during a lung biopsy or the placement of a chest tube

• Contamination of a sterile field and its contents

• The lack of medical asepsis with contamination

• Retained sharps and other surgical instruments after a surgical procedure

The prevention, signs, symptoms and treatments for these inadvertent and accidental and unexpected responses unexpected responses to therapy and procedures have been discussed throughout this NCLEX RN review.

Some of the normal and/or relatively commonly occurring, but undesirable, responses to treatments, therapies, interventions and procedures include:

• Healthcare associated infections (HAI) such as ventilated associated pneumonia (VAP), central line associated blood infections (CLABI), surgical site infections (SSI), ventilator associated pneumonia (VAP), and catheter associated urinary tract infections (CAUTI) and other infections such as pneumonia which can occur simply as the result of infections spread in facilities and institutions that have many clients with multiple infections and the infectious complications of intravenous catheters

• The undesirable side effects, complications and adverse responses to medications and fluid administration

The prevention, signs, symptoms and treatments for these unexpected responses to various other treatments, therapies, interventions and procedures have been discussed throughout this NCLEX RN review.

Recognizing the Signs and Symptoms of Complications and Intervening Appropriately When Providing Client Care

Again, the signs, symptoms, preventive measures, complications and interventions for a wide variety of medical diseases and disorders, including emergency medical situations, were discussed and described throughout this NCLEX RN review.

Promoting the Recovery of the Client From an Unexpected Response to Therapy

As discussed in the previous sections of this NCLEX RN review entitled "Identifying External Factors That May Interfere with Client Recovery", "Promoting Client Progress Toward Recovery From an Alteration in Body Systems" and "Implementing Interventions to Manage the Client's Recovery from an Illness", nurses play an highly important role in the promotion of the client's recovery from an unexpected response to therapy in the same manner that they do for a primary disorder.

For example, urinary tract infections, surgical wound infections and mechanical ventilator associated infections are assessed and treated and the client is then evaluated in terms of these responses to these interventions and treatments.

RELATED CONTENT:

• Alterations in Body Systems
• Fluid and Electrolyte Imbalances
• Hemodynamics
• Illness Management
• Medical Emergencies
• Pathophysiology
• Unexpected Responses to Therapies (Currently here)

SEE – Physiological Adaptation Practice Test Questions

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Alene Burke, RN, MSN

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.