9, NUR 206
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be troponins T and I. creatine kinase-MB (CK-MB). myoglobin. low-density lipoprotein (LDL) cholesterol.
1
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? Muted systolic murmur Upper extremity weakness Oxygen saturation of 92% Dyspnea on exertion
4 Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.
4. A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country "to settle some issues with family members." The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Protesting the unfairness of death b. Anxiety about unfinished business c. Fear of having lived a meaningless life d. Restlessness about the uncertainty of prognosis
ANS: B The patient's statement indicates that there is some unfinished family business that the patient would like to address before dying. There is no indication that the patient is protesting the prognosis, feels uncertain about the prognosis, or fears that life has been meaningless.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) Administer a acetylcysteine (Mucomyst) as ordered Insert a central venous catheter. Assess blood urea nitrogen (BUN) and creatinine results. Insert a Foley catheter. Assess for allergies to iodine. Administer intravenous fluids.
Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results.
The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.
a b d c Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done
The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.
a b d c The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.
A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) Facilitating pleural fluid sampling Assisting with chest tube insertion Providing antipyretics as needed Performing frequent respiratory assessment Suctioning deeply every 4 hours
a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? Weak chest wall movement Patient unable to recall the correct date Laryngospasm Complaint of nausea
weak chest wall movement, The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles, which can lead to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are not as great of concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm is not a concern.
Which patients are most at risk for developing infective endocarditis (select all that apply.)? Man with complaints of chest pain and shortness of breath Adolescent with exertional palpitations and clubbing of fingers Patient with end-stage renal disease on peritoneal dialysis Homeless man with history of intravenous drug abuse Older woman with disseminated coccidioidomycosis
Older woman with disseminated occidioidomycosis Homeless man with history of intravenous drug abuse Patient with end-stage renal disease on peritoneal dialysis
The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? Patient drinks wine three to four times a week. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis. Patient takes a daily multivitamin tablet. Patient checks BP daily just after getting up.
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The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? Reduction in patient complaints of chest pain Reduced dyspnea with the head of bed at 30 degrees Weight loss of 2 pounds in 24 hours Hourly urine output greater than 60 mL
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To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? Low-density lipoprotein (LDL) B-type natriuretic peptide (BNP) Troponin Homocysteine (Hcy)
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The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? Generalized myalgia Complaint of fatigue Leukocytosis Irregular pulse
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2. The nurse is caring for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination? a. "If CPR does not restore a heartbeat, the brain cannot function." b. "Brain death has occurred if there is not any breathing or brainstem reflexes." c. "Brain death has occurred if a person has flaccid muscles and does not awaken." d. "If respiratory efforts cease and no apical pulse is audible, brain death is present."
ANS: B The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.
In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply.)? Cyanosis Tripod position pursed-lip breathing Kussmaul's respirations accessory muscle use increased AP diameter
Tripod position and Accessory muscle use pursed-lip breathing
Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? Ask the patient to request assistance when getting out of bed. Teach the patient that headaches may occur with this medication. Encourage the use of hard candy to prevent dry mouth. Instruct the patient to ask for help if heart palpitations occur.
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Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of peptic ulcer disease. myocardial infarction (MI). asthma. daily alcohol use.
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A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? Heart rate is between 60 and 100 beats/minute. Patient's chest x-ray indicates clear lung fields. Blood pressure (BP) is less than 140/90 mm Hg. Patient reports decreased exertional dyspnea.
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A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? A 68-year-old who has dependent edema and clubbed fingers A 74-year-old with a chronic cough and thick, tenacious secretions A 46-year-old with a 30-pack-year history of smoking A 52-year-old in a tripod position using accessory muscles to breathe
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A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? Serum potassium level 3.0 mEq/L after 1 week of therapy Weight increase from 120 pounds to 122 pounds over 3 days Presence of 1 to 2+ edema in the feet and ankles Palpable liver edge 2 cm below the ribs on the right side
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A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? Self-administration of inhaled corticosteroids Complications associated with oxygen therapy Use of long-acting b-adrenergic medications Side effects of sustained-release theophylline
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A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? Patient's breath sounds are clear to auscultation. Patient's temperature is less than 100.4° F orally. Patient drinks 2 to 3 L of fluid in 24 hours. Patient uses the spirometer 10 times every hour.
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A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? Tying a square knot at the back of the neck Using half-strength peroxide for cleansing Holding the device securely when changing ties Suctioning the client first if secretions are present
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An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? Blood pressure (BP) of 88/42 mm Hg Complaints of fatigue 2+ pedal edema Heart rate of 56 beats/minute
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The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis? The patient complains about a productive cough every winter for 3 months. The patient denies having any respiratory problems until the last 12 months. The patient tells the nurse about a family history of bronchitis. The patient's history indicates a 30 pack-year cigarette history.
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What information should the nurse collect when assessing the health status of a community? Most common causes of death Education level of the individuals Air pollution levels Number of health food stores
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A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? Assess the ability to swallow before using the fenestrated tube. Inflate the tracheostomy cuff during use of the fenestrated tube. Leave the tracheostomy inner cannula inserted at all times. Place the decannulation cap in the tube before cuff deflation.
1 Assess the ability to swallow before using the fenestrated tube. Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube.
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? Appropriate use of cough suppressants Safety concerns with home oxygen therapy Purpose of antibiotic therapy Ways to limit oral fluid intake
1 Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? Blood pressure 137/88 mm Hg 25 mL urine output over last hour Weak pedal pulses Absent bowel sounds
1 The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that b-blockers or other antihypertensive medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a decrease in level of consciousness. a nonsustained episode of ventricular tachycardia. bleeding from the gums. increase in blood pressure.
1 The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? Teaching patients about the need for adult pertussis immunizations Encouraging patients to complete the prescribed course of antibiotics Providing supportive care to patients diagnosed with pertussis Teaching family members about the need for careful hand washing
1 The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.
The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? "I can use my nasal decongestant spray until the congestion is all gone." "I will watch for changes in nasal secretions or the sputum that I cough up." "I can take acetaminophen (Tylenol) to treat my discomfort." "I will drink lots of juices and other fluids to stay well hydrated."
1 The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? Use of accessory muscles in breathing Peak expiratory flow rate of 240 L/minute Pulse oximetry reading of 91% Respiratory rate of 26 breaths/minute
1 Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? The patient takes propranolol (Inderal) for hypertension. The patient uses acetaminophen (Tylenol) for headaches. The patient has chronic inflammatory bowel disease. The patient has a history of pneumonia 6 months ago.
1 beta-Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy.
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? A 76-yr-old nursing home resident A 36-yr-old female patient who is pregnant A 42-yr-old patient who has a 15 pack-year smoking history A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis A 24-yr-old patient who has allergies to penicillin and cephalosporins
1 2 4
A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) Osler's nodes Cardiac murmur Abdominal bloating Weight gain Night sweats
1 2 5 Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and Osler's nodes on palms of the hands and soles of the feet. Abdominal bloating is a manifestation of heart transplantation rejection.
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to check the blood pressure (BP) with a home BP monitor at least once a day. move slowly when moving from lying to sitting to standing. increase the dietary intake of high-potassium foods. make an appointment with the dietitian for teaching.
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The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply.)? Left ventricular function is documented. Controlling dysrhythmias will eliminate HF. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge Prescription for digoxin (Lanoxin) at discharge Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
1 3 5 - Left ventricular function is documented. - Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge - Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen Rationale: The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Increase the client's oxygen during activity. Pace activities, allowing for adequate rest. Administer sleeping medication. Perform most activities for the client.
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A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? Deficient knowledge related to lack of education about COPD Chronic low self-esteem related to increased physical dependence Complicated grieving related to expectation of death Ineffective coping related to unknown outcome of illness
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A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? Place the patient on a low-sodium diet. Perform chest physiotherapy every 4 hours. Schedule a sweat chloride test. Arrange for a hospice nurse visit.
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During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to auscultate both the carotid arteries for the presence of a bruit. assess the patient for symptoms of left ventricular hypertrophy. ask the patient about risk factors for atherosclerosis. document that the PMI is in the normal anatomic location.
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Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? Perform percussion before assisting the patient to the drainage position. Give the ordered albuterol (Proventil) before the patient receives the therapy. Schedule the procedure 1 hour after the patient eats. Maintain the patient in the lateral position for 20 minutes.
2
A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? "Do you have any metal implants or prostheses?" "Have you taken any bronchodilators in the past 6 hours?" "Are you claustrophobic?" "Are you allergic to shellfish?"
2 Bronchodilators are held before pulmonary function testing (PFT) so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before PFTs. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? Teach the patient about the high risk for infecting others unless treatment is followed. Arrange for a daily noon meal at a community center where the drug will be administered. Arrange for a friend to administer the medication on schedule. Give the patient written instructions about how to take the medications.
2 Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? Acetaminophen (Tylenol) Piperacillin/tazobactam (Zosyn) Codeine Guaifenesin (Robitussin)
2 Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? Low-density lipoprotein (LDL) B-type natriuretic peptide (BNP) Troponin Homocysteine (Hcy)
2 Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? Notify the health care provider immediately about any bloody or foul-smelling sputum. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Teach the patient to avoid the use of over-the-counter expectorants. Assist the patient with chest physiotherapy and postural drainage.
2 Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? Place on bed rest for at least 4 hours after bronchoscopy. Notify the health care provider about blood-tinged mucus. Elevate the head of the bed to 80 to 90 degrees. Keep the patient NPO until the gag reflex returns.
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A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? "Surgery is the treatment of choice for stage I lung cancer." "Tell me what you know about the various treatments available." "Are you afraid that the surgery will be very painful?" "Did you have bad experiences with previous surgeries?"
2 More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery
In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL
2 Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? Prepare patient for a spiral computed tomography (CT). Elevate the head of the bed to a semi-Fowler's position. Administer anticoagulant drug therapy. Notify the patient's health care provider.
2 The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? Administration of an inhaled bronchodilator Insertion of a chest tube with a chest drainage system Emergency pericardiocentesis Stabilization of the chest wall with tape
2 The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? Oxygen flow should be increased if the patient has more dyspnea. Oxygen use can improve the patient's prognosis and quality of life. Storage of oxygen tanks will require adequate space in the home. Travel opportunities will be limited because of the use of oxygen.
2 The use of home oxygen improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable oxygen concentrators.
Which information will the nurse include in the asthma teaching plan for a patient being discharged? Hold your breath for 5 seconds after using the bronchodilator inhaler. Tremors are an expected side effect of rapidly acting bronchodilators. Use the inhaled corticosteroid when shortness of breath occurs. Inhale slowly and deeply when using the dry powder inhaler (DPI).
2 Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.
A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) White blood cell (WBC) count: 72,000/mm Prothrombin time: 35 seconds Serum sodium: 130 mEq/L Blood urea nitrogen (BUN): 19 mg/dL International normalized ratio (INR): 6.3
2,5 Rifampin can cause liver damage, evidenced by the clients high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this clients problem. ***I am confused by this as normal WBC is 5,000 - 10,000. **
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) Drainage of 75 mL/hr Tracheal deviation Production of pink sputum Pain at insertion site Sudden onset of shortness of breath
2,5 Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care? Oxygen therapy at 2 liters per nasal cannula Complete bedrest with frequent repositioning Assistance with activities of daily living Physical therapy activities every day
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A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to increase nitroglycerin (Tridil) infusion by 5 mcg/min. increase dopamine (Intropin) infusion by 2 mcg/kg/min. give IV morphine sulfate 4 mg. give IV diazepam (Valium) 2.5 mg.
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After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? Bilateral nose swelling and bruising Inability to breathe through the nose Clear nasal drainage Complaint of nasal pain
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The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? Remind the patient about the importance of taking medications. Visit the patient daily to administer the prescribed medications. Use a marked pillbox to set up the patient's medications. Discuss the option of moving to an assisted living facility.
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The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril. Which patient statement indicates that more teaching is needed? "The doctor may order a blood potassium level occasionally." "I will call the doctor if I notice that I have a frequent cough." "A little swelling around my lips and face is okay." "The medication may not work as well if I take any aspirin."
3
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? The patient has a loud systolic murmur across the precordium. The patient has a palpable thrill felt over the left anterior chest. The patient has bilateral crackles. The patient has bilateral, 4+ peripheral edema.
3
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? Determine when the dyspnea started. Obtain the forced expiratory volume (FEV) flow rate. Listen to the patient's breath sounds. Ask about inhaled corticosteroid use.
3 Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? Decrease in premature atrial contractions Decrease in premature ventricular contractions Increase in the patient's heart rate Increase in strength of peripheral pulses
3 Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
3 Normal pH is 7.35-7.45. Values less than 7.35 indicate acidosis. Normal value for HCO3¯ is 22--26 mEq/L. Because the PaCO2 is normal and the HCO3¯ is low, below the normal, the source of the acidosis is metabolic. The patient is in metabolic acidosis. https://www.youtube.com/watch?v=URCS4t9aM5o
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? Heart rate of 110 beats/minute Large bruised area on the chest Paradoxic chest movement Complaint of chest wall pain
3 Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? The patient's respirations are shallow. The patient's respiratory rate is 32 breaths/minute. The patient's PaO2 is 45 mm Hg. The patient's PaCO2 is 33 mm Hg.
3 The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? Lung expansion is decreased bilaterally. Hyperresonance to percussion is present. Respirations are 36 breaths/minute. Anterior-posterior chest ratio is 1:1.
3 The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? Respiratory rate of 28 breaths/minute Resting pulse oximetry (SpO2) of 85% Weak, nonproductive cough effort Large amounts of greenish sputum
3 The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about continuous pulse oximetry. effects of leukotriene modifiers. a1-antitrypsin testing. use of the nicotine patch.
3 When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.
A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? "Pull rather than push or carry items heavier than 5 pounds." "Take a walk after dinner every day to build up your strength." "Walk until you become short of breath, and then walk back home." "Gather everything you need for a chore before you begin."
4
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? Assess the patient's oxygen saturation and notify the health care provider. Ventilate the patient with a manual bag and face mask until the health care provider arrives. Cover stoma with sterile gauze and ventilate through stoma. Attempt to reinsert the tracheostomy tube with the obturator in place.
4
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? Petechiae on the inside of the mouth and conjunctiva Increase in heart rate of 15 beats/minute with walking Fever, chills, and diaphoresis Urine output less than 30 mL/hr
4
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? The patient had a heart attack a year ago. The patient has not eaten anything today. The patient's pedal pulses are +1. The patient is allergic to shellfish.
4
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? Discuss the need to rinse the mouth out after using any inhalers. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs). Teach the patient about the use of expectorants. Use a swab to obtain a sample for a rapid strep antigen test.
4
When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? Teach about the importance of monitoring temperature when sore throats occur. Teach about prophylactic antibiotics to those with a family history of rheumatic fever. Vaccinate high-risk groups in the community with streptococcal vaccine. Teach community members to seek treatment for streptococcal pharyngitis.
4
Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? Give acetaminophen (Tylenol) PRN for fever. Arrange for a transesophageal echocardiogram. Administer ceftriaxone (Rocephin) 1 g IV. Order blood cultures drawn from two sites.
4
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? Teach the patient about self-care of the tracheostomy. Determine the need for replacement of the tracheostomy tube. Assess the patient's risk for aspiration. Suction the tracheostomy when needed.
4
After receiving report on the following patients, which patient should the nurse assess first? Patient with infective endocarditis who has a murmur and splinter hemorrhages Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases Patient with rheumatic fever who has sharp chest pain with a deep breath Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
4 Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? Sore throat and frequent cough Myalgia and persistent headache Fever of 100.4° F (38° C) Diffuse crackles in the lungs
4 The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake.
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? Assess the patient's oxygen saturation and notify the health care provider. Ventilate the patient with a manual bag and face mask until the health care provider arrives. Cover stoma with sterile gauze and ventilate through stoma. Attempt to reinsert the tracheostomy tube with the obturator in place.
4 The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? Schedule the patient for directly observed therapy three times weekly. Discuss with the health care provider the need for the patient to use an injectable antibiotic. Teach about treatment for drug-resistant TB treatment. Ask the patient whether medications have been taken as directed.
4 The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? The patient practices by blowing through a straw. The patient's ratio of inhalation to exhalation is 1:3. The patient inhales slowly through the nose. The patient puffs up the cheeks while exhaling.
4 The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.
Following laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action that the nurse should take is to check the vital signs for indications of hemorrhage. turn the patient to the side to relieve pressure on the right leg. report the patient's complaint to the surgeon. check the chart for preoperative assessment data.
4 The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Ciprofloxacin (Cipro) 400 mg IV Acetaminophen (Tylenol) rectal suppository Chest x-ray via stretcher Blood cultures from two sites
ANS: 4 Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
14. The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care? a. Determine the patient's wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the patient and family. d. Encourage the patient to talk about any fears or unresolved issues.
ANS: A The nurse's initial action should be to assess the patient's wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.
8. The nurse is caring for a terminally ill patient who is experiencing continuous and severe pain. How should the nurse schedule the administration of opioid pain medications? a. Plan around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests them. c. Suggest small analgesic doses to avoid decreasing the respiratory rate. d. Offer enough pain medication to keep the patient sedated and unaware of stimuli.
ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.
5. A patient with terminal cancer is being admitted to a family-centered inpatient hospice. The patient's spouse visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which provisional nursing diagnosis is appropriate for the patient's spouse? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Hopelessness related to knowledge deficit about cancer d. Caregiver role strain related to spouse's complex care needs
ANS: A The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious.
1. Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Provide postmortem care to the patient. b. Encourage the family members to talk with and reassure the patient. c. Determine how frequently physical assessments are needed for the patient. d. Teach family members about commonly occurring signs of approaching death. e. Administer the prescribed morphine sulfate sublingual as necessary for pain control.
ANS: A, B, E Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice. Patient and family teaching and assessment and planning of frequency for assessments are skills that require registered nurse level education and scope of practice.
3. A patient in hospice is manifesting a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min. Which statement, if made by the nurse to the patient's family member, is most appropriate? a. "These vital signs will continue to increase until death finally occurs." b. "These vital signs are an expected response now but will slow down later." c. "These vital signs may indicate an improvement in the patient's condition." d. "These vital signs are a helpful response to the slowing of other body systems."
ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in a dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement or compensation, and it would be inappropriate for the nurse to indicate this to the family.
15. Which action is most important for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? a. Let the family decide how to tell the patient about the terminal diagnosis. b. Ask the patient and family about their preferences for care during this time. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside.
ANS: B Because cultural beliefs may vary among people of the same ethnicity, the nurse's best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family.
10. A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? a. Contact a grief counselor as soon as possible. b. Cry along with the patient's family members. c. Leave the home quickly to allow the family to grieve privately. d. Consider leaving hospice work because patient losses are common.
ANS: B It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is supportive. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse's initial action at this time should be to share the grieving process with the family.
7. A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death.
ANS: B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient's concerns. Telling the patient that everything is being done does not address the patient's fears about dying, especially because the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there.
12. The son of a dying patient tells the nurse, "Mother doesn't really respond any more when I visit. I don't think she knows that I am here." Which response by the nurse is appropriate? a. "Cut back your visits for now to avoid overtiring your mother." b. "Withdrawal can be a normal response in the process of dying." c. "Most dying patients don't know what is going on around them." d. "It is important to stimulate your mother so she can't retreat from you."
ANS: B Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be "present" with the patient, talking softly and making physical contact in a way that does not demand a response from the patient.
1. The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate? a. Suction the patient's mouth. b. Administer oxygen via face mask. c. Document Cheyne-Stokes respirations. d. Place the patient in high Fowler's position.
ANS: C Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent. There is also no need for supplemental oxygen by face mask or suctioning the patient.
13. Which patient should the nurse refer for hospice care? a. A 70-yr-old patient with lymphoma whose children are unable to discuss issues related to dying b. A 60-yr-old patient with chronic severe pain as a result of spinal arthritis and vertebral collapse c. A 40-yr-old patient with AIDS-related dementia who needs palliative care and pain management d. A 50-yr-old patient with advanced liver failure whose family members can no longer provide care in the home
ANS: C Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients.
11. A middle-aged patient tells the nurse, "My mother died 4 months ago, and I just can't get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate? a. Hopelessness related to inability to resolve grief b. Complicated grieving related to unresolved issues c. Anxiety related to lack of knowledge about normal grieving d. Chronic sorrow related to ongoing distress about loss of mother
ANS: C The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient's grief is unusual or pathologic, which is not the case.
9. The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Teach the patient about the purpose of chemotherapy and radiation. c. Encourage the patient to discuss past life events and their meanings. d. Accomplish a thorough head-to-toe assessment several times a week.
ANS: C The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient's life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Discussion of cancer risk factors and therapies is not appropriate.
6. As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first? a. Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan. b. Invite the patient to add a notarized advance directive in the health record. c. Advise the patient to designate a person to make future health care decisions. d. Ask if the decision has been discussed with the patient's health care provider.
ANS: D A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient's wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient's current concern with possible resuscitation.
