Adult Health II (Med Surge) Nursing

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"

1, "Does the pain in your stomach radiate to your back? (Rat) A patient who presents to the ER with acute and pain that radiates to their back may have acute pancreatitis.

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply. 1.Insulin 2.Morphine 3.Dicyclomine 4.Pancrelipase 5.Pantoprazole 6.Acetazolamide

2,3,5,6 Morphine, Dicyclomine, Pantoprazole, Acetazolamide (Rat) Medications used to treat acute pancreatitis include pain medications like morphine, antispasmodics such as dicyclomine, PPI such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Note: Insulin is used in chronic pancreatitis to treat DM or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present? 1.A sunken and hidden stoma 2.A narrow and flattened stoma 3.A stoma that is dusky or bluish 4.A stoma that is elongated with a swollen appearance

4, A stoma that is elongated with a swollen appearance

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea 2.Black, tarry stools 3.Hyperactive bowel sounds 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back

4,5,6 (Rat) Grayish - blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage.

An adult Veteran has survived an episode of shock and will DC home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this Veteran. What aspect of his care should be prioritized by the home health nurse? A. Providing supervision to home health aids in providing necessary patient care B. Assisting the Veteran and family to identify and mobilize community resources C. Providing ongoing medical care during the family's rehabilitation phase D. Reinforcing the importance of continuous assessment with the family

B. Assisting the Veteran and family to identify and mobilize community resources

The nurse is caring for a Veteran with an endotracheal tube who is on a ventilator. When assessing the Veteran, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A. Between 10 and 15 mmHg B. Between 15 and 20 mmHg C. Between 20 and 25 mmHg D. Between 25 and 30 mmHg

B. Between 15 and 20 mmHg (RAT) Maintain the cuff pressure set between these numbers to prevent extra pressure on the tracheal wall.

A Veteran is scheduled for catheter ablation therapy. When describing this procedure to the Veterans family, the nurse should address what aspect of the treatment? A. Resetting of the hearts contractility B. Destruction of specific cardiac cells C. Correction of structural cardiac abnormalities D. Clearance of partially occluded coronary arteries

B. Destruction of specific cardiac cells (RAT) A catheter ablation is a procedure that "obliterates" heart cells that are causing the increased, rapid heart rates (tachydysrhythmias). It does not reset the heart nor does it causse alterations in the hearts structure or vascular network.

The nurse is preparing a DC for a Veteran after a thoracotomy. The Veteran is going home on O2 therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this Veteran? A. Safe technique for self-suctioning of secretions B. Technique for performing postural drainage C. Correct and safe use of oxygen therapy equipment D. How to provide safe and effective tracheostomy care

C. Correct and safe use of oxygen therapy equipment (RAT) Thoracotomy Education/Teaching: Anytime a patient is being discharged with any type of equipment, it is the responsibility of the nurse to educate the patient about the correct and safe use of oxygen therapy equipment.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A. Older adults have less compliant lung tissue than younger adults B. Older adults are not normally candidates for pneumococcal vaccination C. Older adults often lack the classic signs and symtoms of pneumonia D. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.

C. Older adults often lack the classic signs and symtoms of pneumonia (RAT) Pneumonia - Assess for hypoxemia by applying the pulse oximetry and by assessing ABG's. Education/Teaching: Educate others that older adults are at more risk of getting pneumonia because this patient population do not present with the same s/s as a younger person would thus preventing early treatment that is lifesaving.

Following cardiac resuscitation, a Veteran has been placed in a state of mild hypothermia before being transferred to the CIU. The nurses assessment reveals that the Veteran is experiencing neuromuscular paralysis. How should the nurse best respond. A. Administer hypertonic IV solution B. Administer a bolus of warned NS C. Reassess the Veteran in 15 minutes D. Document this as an expected assessment finding

D. Document this as an expected assessment finding

A Veteran is being treated in the ICU for neurogenic shock secondary to spinal cord injury. Despite aggressive interventions, the Veterans MAP has fallen to 55 mmHg. The nurse should gauge the onset of AKI by referring to what lab findings? Select all that apply. A. BUN B. USG C. Alkaline phosphate level D. Creatinine E. Serum albumin level

(A B D) BUN, USG and Creatinine (RAT) Neurogenic Shock Nursing Assessment - Patient arrived at the ER after being involved in a car accident resulting in a spinal cord injury. The data presented is a MAP of 55mmHg and the nurse anticipates acute kidney injury by assessing the following LABS: BUN, Creatinine and urine specific gravity. The nurse notes that (AKI) Acute Kidney Injury is characterized by an increased BUN & Creatinine., fluid level shifts, acid imbalances and a loss of the kidneys ability to control BP that is directly r/t a loss in fluid volume statues.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1.Sitting up 2.Lying flat 3.Leaning forward 4.Drawing the legs to the chest

2 Lying flat (Rat) The pain of acute pancreatitis is aggravated by lying supine or walking.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1.Checking for normal serum electrolyte levels 2.Checking for normal pH of the gastric aspirate 3.Checking for proper nasogastric tube placement 4.Checking for the presence of bowel sounds in all 4 quadrants

4, Checking for the presence of bowel sounds in all 4 quadrants (Rat) Bowel sounds indicates that the obstruction has resolved.

Pancreatin is prescribed for a client with postgastrectomy syndrome. Which assessment finding would indicate a therapeutic effect of this medication? 1.The client's appetite improves. 2.The client experiences weight loss. 3.Vitamin B12 deficiency is controlled. 4.The stool is less fatty and decreases in frequency.

4, The stool is less fatty and decreases in frequency (Rat) Pancreatin aids in the digestion of protein, carbs, and fat in the GI tract. It is used to treat steatorrhea associated with postgastrectomy syndrome after bowel resection.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1.Ibuprofen 2.Ranitidine 3.Acetaminophen 4.Acetylsalicylic acid

4, Tylenol (Rat) This medication can cause hepatoxicity.

The nurse is caring for a Veteran who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the Veteran from a ventilator, the nurse is aware that the weaning of the Veteran will progress in what order? A. Removal from the ventilator, tube, and then oxygen B. Removal from oxygen, ventilator, and then tube C. Removal of the tube, oxygen, and then ventilator D. Removal from the oxygen, tube, and then ventilator

A. Removal from the ventilator, tube, and then oxygen (RAT) Ventilator Weaning When there is an order to remove the patient's ventilator you want to remember to complete the weaning in 3 steps: 1st Remove the ventilator 2nd Remove the endotracheal tube 3rd Remove the oxygen.

The nurse is caring for a Veteran suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the Veterans symptoms from those of a cardiac etiology? A. Carboxyhemoglobin level B. Brain natriuretic peptide (BNP) level C. C-reactive protein (CRP) level D. Complete blood count

B. Brain natriuretic peptide (BNP) level (RAT) (ARDS) Acute Respiratory Death Syndrome The cause of ARDS can be related to the heart or the lungs, thus the HCP may order LABS particularly a (BNP) Brain Natriuretic Peptide (BNP) level; the BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructors best response? A. Cardioversion is done on a beating heart; defibrillation is not B. The difference is the timing of the delivery of the electric current C. Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not. D. Cardioversion is always attempted before defibrillation because it has fewer risks.

B. The difference is the timing of the delivery of the electric current (RAT) In cardioversion the delivery of the electrical current is synchronized with the veteran, in defibrillation the delivery is immediate and unsynchronized. Both can be done on a beating heart if the heart has a dysrhythmia.

The nurse is performing nasotracheal suctioning on a Veteran and obtains copious amounts of secretions from the Veterans airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A. Continue suctioning the Veteran until no more secretions are obtained B. Perform chest physiotherapy rather than nasotracheal suctioning C. Wait several minutes and then repeat suctioning D. Perform postural drainage and then repeat suctioning.

C. Wait several minutes and then repeat suctioning (Rat) Tracheal Suctioning Note: when suctioning a patient be sure to ventilate the patient and to wait several minutes before continuing suctioning.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1.Fever 2.Positive Cullen's sign 3.Complaints of indigestion 4.Palpable mass in the left upper quadrant 5.Pain in the upper right quadrant after a fatty meal 6.Vague lower right quadrant abdominal discomfort

Fever w/dehydration, C/o indigestion/RUQ pain after a fatty meal that radiates to the back to the right side near the shoulder/scapula. N&V

The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply. A. Time frame of exposure B. Type of respiratory protection used C. Immunization statues D. Breath sounds E. Intensity of exposure

(A B D E) Time frame of exposure Type of respiratory protection used Breath sounds Intensity of exposure

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurse identify? Select all that apply. A. Anaphylactic B. Hypovolemic C. Cardiogenic D. Septic E. Neurogenic

(A D E) Anaphylactic, Septic, Neurogenic (RAT) Note - The process that leads up to circulatory shock provide the basis for the further subclassifications of shock into these 3 subtypes: 1 Anaphylaxis 2 Neurogenic 3 Septic Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? 1."Do you abuse alcohol?" 2."Do you have any known cardiac disease?" 3."Does your type of employment cause you to have exposure to chemicals?" 4."Have you ever been told that you have had obstruction to your biliary ducts?"

1, "Do you abuse ETOH?" (Rat) Laennec's cirrhosis is r/t long term ETOH use; Cardiac cirrhosis is associated with long-term right sided HF. Post-necrotic cirrhosis is a result of hepatotoxins, chemicals, or infections or a metabolic d/o. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-tern obstruction of bile ducts.

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? 1."It will cause diaphoresis and diarrhea." 2."I have to monitor for hiccups and diarrhea." 3."It will be associated with constipation and fever." 4."I have to monitor for fatigue and abdominal pain."

1, "It will cause diaphoresis and diarrhea."

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1."The medication will cause constipation." 2."I need to take the medication with meals." 3."I may have increased sensitivity to sunlight." 4."This medication should be taken as prescribed."

1, "This medication will cause constipation" (Rat) This medication is an anti-inflammatory sulfonamide. Constipation is not a SE associated with this medication. It can cause photosensitivity, and the patient is instructed to avoid sunlight and UV light. Take with meals.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.Orthopnea and dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness

1, 2, 3, 5 Orthopnea and SOB, Petechiae and ecchymosis, Inguinal or umbilical hernia and And distention and tenderness (Rat) Ascites can cause physical problems because of the over distended abdomen and resultant pressure on internal organs and vessels.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort

1, Malaise

Cholestyramine resin is prescribed for a client with an elevated serum cholesterol level. The nurse should instruct the client to take the medication in which way? 1.After meals 2.Mixed with fruit juice 3.Via a rectal suppository 4.At least 3 hours before meals

2 Mixed with fruit juice (Rat) This medication functions by binding with bile salts in the intestines to form a compound that is excreted in the feces. The patient should be instructed to mix the medication with 3-6 oz of water, milk, fruit juice, or soup. Administer before meals.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1.Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only 3 large meals daily.

2, Increase intake of fluids, including juices

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? 1.Weight loss 2.Peripheral edema 3.Capillary refill of 5 seconds 4.Bleeding from previous puncture sites

2, Peripheral edema (Rat) Note albumin is needed to maintaining the osmolality of the blood (the fluid flow of the blood). When the albumin us decreased, this can lead to a low fluidness in the blood which can lead to peripheral edema.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.Restlessness 2.Presence of asterixis 3.Complaints of fatigue 4.Decreased serum ammonia levels

2, Presence of asterixis (Rat) The presence of this is an early sign of hepatic encephalopathy.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1.Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.

2, The Facal pH is acidic (Rat) Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The therapeutic effect is for the patient to have 2-3 soft stools per day. This causes ammonia to leave the circulatory system and move into the colon for excretion.

A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? 1.Folate 2.Biscodyl 3.Ferrous sulfate 4.Cyanocobalamin

2. Biscodyl (Rat) The patient with an ileostomy is prone to dehydration because of the location of the stony in the GI tract and should not take laxatives.

The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, which condition should the nurse suspect is occurring in this client? 1.Lactic acidosis 2.Glycogenolysis 3.Gluconeogenesis 4.Glucose metabolism

3, Gluconeogenesis (Rat) is the production of glucose for energy from protein and fat stores in the body. This can happen when someone goes on extreme dieting and also with DM.

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? 1.Sodium 2.Creatinine 3.Hemoglobin 4.Ammonia

3, Hgb (Rat) Hgb trends will determine if the tube is effective

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1.Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high-Fowler's position during meals.

3, Limit fluid intake at first with meals

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? 1.Maintain a high-carbohydrate diet. 2.Increase fluid intake, particularly at mealtime. 3.Maintain a low-Fowler's position while eating. 4.Ambulate for at least 30 minutes following each meal.

3, Maintain a low-Fowler's position while eating (Rat) The patient should also consider lying down for at least 30 minutes after eating.

A client with gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure? 1.Portal vein 2.Celiac artery 3.Vagus nerve 4.Pyloric valve

3, Vagus nerve (Rat) Note that the vagus nerve helps to manage the complex processes in your digestive tract, including signaling the. muscles in the stomach to contract and push food into the small intestine. A damaged vagus nerve or surgery that alters the vagus nerve function can't send signals normally to your stomach muscles. A vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid.

The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease? 1.Blood in the stool 2.Chalky gray stool 3.Loose, watery stool 4.Dry, hard, constipated stool

3, loose, watery stool (Rat) Crohn's disease is characterized by non bloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which mostfrequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance

4 FLuid and electrolyte imbalance

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in Veterans who are being treated for shock. What interventions should be specified in the Veterans plan of care while the Veteran is ventilated? A. Performing frequent oral care B. Maintaining the Veteran in a supine position C. Suctioning the Veteran every 15 minutes unless contraindicated D. Administering prophylactic antibodies, as ordered

A. Performing frequent oral care

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.Elevated lipase level 2.Elevated lactase level 3.Elevated trypsin level 4.Elevated amylase level 5.Elevated sucrase level

1, 3, 4 Elevated lipase, trypsin and amylase (Rat) Lipase, trypsin and amylase are produced in the pancreases and aid in the digestion of fats, starches, and proteins. Lactase is made in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is also made in the small intestines and converts sucrose into glucose and fructose.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1.Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine

1, 3, 4, 5 Jaundice Clay-colored stools Elevated bilirubin Dark or tea-colored urine (Rat) There are 3 stages associated with viral hepatitis. Stage 1: Flu like symptoms Stage 2: Jaundice, elevated bilirubin, dark or tea-colored urine & clay colored stools Stage 3: The jaundice and clay color stool color returns to normal.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1.Administer stool softeners as prescribed. 2.Instruct the client to limit fluid intake to avoid urinary retention. 3.Encourage a high-fiber diet to promote bowel movements without straining. 4.Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5.Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

1, 3,4 Administer stool softness as prescribed, Encourage a high - fiber diet to promote BM w/o straining & Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1.Change the dressing. 2.Continue to monitor the drainage. 3.Notify the primary health care provider (PHCP). 4.Use a pen to circle the amount of drainage on the dressing.

1, Change the dressing (Rat) Serosanguinous drainage with a small amount of bile is expected form the Penrose drain for the 1st 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing usually covers the site and should be changed if dressing covers the site and should be changed if wet to prevent infection and skin excoriation.

The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? 1.Cystic duct 2.Liver canaliculi 3.Common bile duct 4.Right hepatic duct

1, Cystic duct (Rat) The gallbladder receives bile from the liver through the cystic duct.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish-brown drainage

1, Dark red drainage (Rat) Dark red drainage for the first 12 hours is normal where as dark red drainage 24 hours after gastric surgery is not normal.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1, Inability to pass gas is a iconic manifestation of a paralytic ileus.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider? 1.Elevated serum bilirubin level 2.Below normal hemoglobin concentration 3.Elevated blood urea nitrogen (BUN) level 4.Elevated erythrocyte sedimentation rate (ESR)

1, elevated serum bilirubin level (Rat) Lab indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. The ESR is not the correct answer because the ESR only identifies that there is inflammation somewhere in the body.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hr to keep the vein open.

1,2 &5 Maintain NPO status Encourage coughing and deep breathing. Give hydromorphone IV as ordered for pain.

The OR nurse is setting up a water-seal chest drainage system for a Veteran who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cmH2O B. 15 cmH2O C. 10 cmH2O D. 5 cmH2O

A. 20 cmH2O (RAT) The amount of suctioning is determined by the water level. It is usually set at 20 cmH2O; adding more fluid results in more suction.

The nurse in the ED is caring for a Veteran recently admitted with likely myocardial infarction. The nurse understands that the Veterans heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? A. Dysrhythmias B. Increase in BP C. Increase in HR D. Decrease in oxygen demands

A. Dysrhythmias (RAT) Cardiogenic Shock Assessment: Cardiogenic shock is associated with MI; MI is associated with A.fib. (an irregular heart rhythm that can cause blood clots to circulate in the vessels and contribute to a stroke). The patient with cardiogenic shock may present with chest pain (angina) and dysrhythmias.

The nurse and the medical team in SICU are caring for a Veteran who converts into V.Fib. The Veteran was defibrillated unsuccessfully and is still in V.Fib. The SICU nurse Hillary and her student Ashley will expect to administer what through the CVAD? A. Epinephrine 1 mg IV push B. Lidocaine 100 mg IV push C. Amiodarone 300 mg IV push D. Sodium bicarbonate 1 amp IV push

A. Epinephrine 1 mg IV push (RAT) Epinephrine 1 mg IV push should be administered ASAP after the 1st unsuccessful defibrillation and then every 3-5 minutes. Note that Amiodarone is a medication administered IV to manage the rhythms and are administered after the Epi is not working, it's like phase 2 to convert a Veteran back to a normal/regular rhythm.

The nurse is caring for a Veteran in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A. Frequent monitoring of VS, monitoring the central line site, and providing accurate drug titration. B. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C. Reviewing the lab findings, monitoring UO, and assessing for peripheral edema D. Routine monitoring of VS, monitoring the PIV site, and providing early DC instructions.

A. Frequent monitoring of VS, monitoring the central line site, and providing accurate drug titration. (RAT) IV Dopamine (Vasoactive Medication) Assessment/Nursing Intervention: Assess VITAL SIGNS Q15 MINUTES until the patient is stable, monitor central line and titrate the medication according the "facility policy aka standing order/MD order." It is important to administer the medication through a central line because the IV dopamine can be harsh on the vessels and cause extravasation.

You are the preceptor of a new graduate nurse in the ICU. You are collaborating in the care of a Veteran who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the Veteran? A. Hypothermia B. Bradycardia C. Coffee ground emesis D. Pain

A. Hypothermia (RAT) Hypovolemic Shock Nursing Intervention: The nurse administers IV bolus of crystalloid of NS or LR to the patient diagnosed with hypovolemic shock to increase the BV and CO. There is a complication associated with the administration of large bolus of IV fluid and it is hypothermia. Assess the patient to prevent hypothermia, the IV fluid may need to be warmed prior to administration. The nurse will also assess for FVO which is another complication of treating hypovolemia so auscultate lung sounds and listen for adventurous lung sounds - crackles (pulmonary edema).

A Veteran the nurse is caring for has a permanent pacemaker implanted with the identification code beginning with VVI. What does this indicate? A. Ventricular paced, ventricular sensed, inhibited B. Variable paced, ventricular sensed, inhibited C. Ventricular sensed, ventricular situated, implanted D. Variable sensed, variable paced, inhibited

A. Ventricular paced, ventricular sensed, inhibited (RAT) The ID VVI means that the ventricles are paced, sensed and inhibited.

A Veteran with a thoracic trauma is admitted to the ICU. The nurse notes the Veterans chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A. A chest tube B. A tracheostomy C. An endotracheal tube D. A feeding tube

B. A tracheostomy (RAT) Subcutaneous Emphysema Subjective Data - Reported patient was involved in a traumatic accident causing thoracic trauma. Objective Data reveals the following - Swollen chest & Neck, on palpitation, crackles in the chest. Medical Management/Nursing Interventions: The nurse should anticipate a tracheostomy tube insertion to maintain airway patency and to prevent airway obstruction.

A Veteran converts from NSR at 88 bpm to A. Fib with a ventricular response at 166 bpm. BP is 168/84 mmHg. RR is 22 bpm with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the Veteran understands that the main goal of treatment is what? A. Decrease SA node conduction B. Control ventricular HR C. Improve oxygenation D. Maintain anticoagulation

B. Control ventricular HR (RAT) The Veteran is experiencing A.Fib, the nurses are responding to treat/reverse the A.fib which alters the ventricular rate. The goal is to control the ventricular rate. Controlling the ventricular rate takes priority because it directly affects the CO. The increased ventricular rate decreases ventricular filling time so not enough blood is filling up the ventricles to send to the rest of the body, thus SV is decreased. Controlling the ventricular rate is the 1st step or initial treatment of choice, followed by anticoagulation with heparin then warfarin (Coumadin).

The nurse is caring for a Veteran with chronic obstructive pulmonary disease (COPD). The Veteran has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the Veteran were experiencing oxygen toxicity? A. Bradycardia and frontal HA B. Dyspnea and substernal pain C. Peripheral cyanosis and restlessness D. Hypotension and tachycardia

B. Dyspnea and substernal pain (RAT) Oxygen toxicity can occur when there is a high concentration of oxygen is given for a long period of time. Oxygen toxicity symptoms include the following: SOB Fatigue Progressive respiratory difficulty Substernal chest pain Restlessness

The nurse in the ICU is caring for a 49-year-old, obese male Veteran who is in shock following a car accident. The nurse is aware that Veterans in shock possess excess energy requirements. What would be the main challenge in meeting this Veterans increased energy demands during prolonged rehabilitation? A. Loss of fat tissue B. Loss of skeletal muscle tissue C. Inability to convert adipose tissue to energy D. Inability to maintain normal body mass

B. Loss of skeletal tissue (RAT) Shock - Nursing Care Plan/Goals are as follows: In the ICU prepare to prevent the complications of shock, to do so you need to know the early signs of shock. Assessment: The nurse notes to assess the patient's skeletal muscle function prior to shock because during shock the body tends to "eat up" energy stores and will pull from the lean muscle 1st, before utilizing energy from fat tissue. Note: Because the body "eats up" the lean, healthy muscle tissue first, the nurse knows that this prolongs the patients recovery time and should educate the patient and the family regarding this.

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A. Apply the paddles directly to the Veterans skin B. Use a conducting medium between the paddles and the skin C. Always use a petroleum-based gel between the paddles and the skin D. Any available liquid can be used between the paddles and the skin

B. Use a conducting medium between the paddles and the skin (RAT) The difference is in the delivery of the electrical current In cardioversion, the delivery of the electrical current is synchronized with the veteran, in defibrillation the delivery is immediate and unsynchronized. Both can be done on a beating heart if the heart has a dysrhythmia.

A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the Veterans exposure risk to toxic substances? A. Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air B. Wear protective attire and devices when working with a toxic substance C. Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxic substances D. Always wear a disposable paper face mask when you are working with inhalable toxins

B. Wear protective attire and devices when working with a toxic substance (RAT)Lung Cancer - Education/Teaching: It is important for the nurse to educate the patient on avoiding toxins by wearing protective equipment when working with toxins. Assessment: The nurse should assess the following after receiving report the patient was exposed to a toxic substance that may have caused ARDS ( no particular order) 1st Time of exposure 2nd Type of respiratory protection used 3rd Breath sounds 4th Intensity of exposure.

The nurse is caring for a Veteran who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the Veteran is hypoxemic? A. Assess the Veterans LOC B. Assess the Veterans extremities for signs of cyanosis C Assess the Veterans O2 Sat level D. Review the Veterans hemoglobin, Hct, and RBC levels

C Assess the Veterans O2 Sat level (RAT) The effectiveness of the Veterans O2 therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available, the ABG's assess O2 saturation.

The ICU nurse is caring for a Veteran in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the Veteran? A. Anaphylaxis B. Decreased O2 consumption C. Abdominal compartment syndrome D. Decreased serum osmolality

C. Abdominal compartment syndrome (RAT) Hypovolemic Shock can lead to complications of when large volumes of fluid are administered such as (ACS) Abdominal Compartment Syndrome.

An adult Veteran with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A. PP interval and RR interval are irregular B. PP interval is equal to RR interval C. Fewer QRS complexes than P waves D. PR interval is constant

C. Fewer QRS complexes than P waves (Rat)There will be more P waves than QRS complexes 3RD DEGREE AV HEART BLOCK AKA ("COMPLETE HEART BLOCK") Note: The P & Q waves are D I V O R C E D!! H EARTS: 40 RHYTHMS: P-P regular, not associated with each other P "WAVES": More P waves than QRS P Q INTERVALS: No PR or PQ intervals QRS WIDTHS: 0.10 Note: If P's and Q's don't agree, then you have a THIRD DEGREE. A 3RD - DEGREE HEART BLOCK AKA A COMPLETE HEART BLOCK CAN'T SUSTAIN ADEQUATE TISSUE PERFUSION. THE AV NODE IS BLOCKED COMPLETELY. As a result thee is no connection between the P wave and the QRS. The Veteran will ultimately require a pacemaker

The nurse is caring for a Veteran in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The Veteran has become hypotensive. What is the cause of this complication to the ARDS treatment? A. Pulmonary hypotension due to decreased CO B. Severe and progressive pulmonary HTN C. Hypovolemia secondary to leakage of fluid into the interstitial spaces D. Increased CO from high levels of PEEP therapy

C. Hypovolemia secondary to leakage of fluid into the interstitial spaces (RAT) Hypotension is associated with hypovolemia secondary to leakage of fluid into the interstitial spaces. NOTE: REMEMBER The BP will be low - so, the patient will be hypotensive, but the patient will have pulmonary hypertension. Note that treatment involves intubation with PEEP, and this too can cause depressed CO thus causing decreased BP - hypotension.

A Veteran presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus - like sputum. The Veteran complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the Veteran for what health problem? A. Pleural effusion B. Pulmonary embolism C. Tracheobronchitis D. Tuberculosis

C. Tracheobronchitis (RAT) Tracheobronchitis Assessment: The patient will present with the following symptoms dry, irritating cough, production of minute mucoid sputum, soreness in the chest (sternal soreness) from coughing, fever, chills , HA, sweats, general malaise.

The nurse is caring for a Veteran who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurses assessment? A. Assessing the Veterans activity level B. Facilitating transthoracic echocardiography C. Vigilant monitoring of the Veterans ECG D. Close monitoring of the Veterans peripheral perfusion

C. Vigilant monitoring of the Veterans ECG (RAT) After a pacemaker is placed it is important for the nurse to monitor ECG's which identifies the HR and rhythm. This take priority over peripheral circulation.

The nurse in a rural nursing hospital has just been notified that she will receiving a Veteran in hypovolemic shock due to a massive hemorrhage after her home birth. You know that the best choice for fluid replacement for this Veteran is what? A. 5% Albumin because it is inexpensive and is always readily available B. Dextran because it increases intravascular volume and counteracts coagulation process. C. Whatever fluid is most readily available in the clinic, due to the nature of the emergency. D. LR solution because it increases volume, buffers acidosis, and is the best choice for Veterans with liver failure.

C. Whatever fluid is most readily available in the clinic, due to the nature of the emergency. (RAT) The best fluid to treat shock varies. In emergencies, the best fluid is often the fluid is ready. There is no specific preference in emergency situations, because crystalloid and colloids can both be administered to restore intravascular volume. Note that because Albumin is very expensive, LR is a good 1st choice.

A Veteran in the ICU has had an endotracheal tube in place for 3 weeks. The MD has ordered that a tracheostomy tube be placed. The Veterans family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best responses? A. The MD may feel that mechanical ventilation will have to be used long-term B. Long-term use of an endotracheal tube diminishes the normal breathing reflex C. When an endotracheal tube is left in too long it can damage the lining of the windpipe. D. It is much harder to breathe through an endotracheal tube than a tracheostomy.

C. When an endotracheal tube is left in too long it can damage the lining of the windpipe. (RAT) Endotracheal Tube The pressure of the endotracheal tube has a required cuff pressure between 15 and 20 mmHg, this is the cuff pressure to be maintained to prevent excess pressure against the tracheal wall. Note: Endotracheal tubes cannot be left in place for no longer than 2-3 weeks. The endotracheal tube left in place for too long may also cause vocal cord paralysis and decrease the patients work of breathing.

The ER nurse is admitting a Veteran experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A. Increased UO B. Decreased HR C. Hyperactive BS D. Cool, clammy skin

D. Cool, clammy skin (Rat) Compensatory Shock Nursing Objective data - the patient may present with GI Bleed and eventually will go into shock. A shock patient may present with compensatory shock and the nurse may feel the skin and note the skin to be cool and clammy. (Rat) The reason is because the body tries to compensate by shunting blood from the rest of the body such as the skin and the kidneys to send blood to the vital organs such as the brain and the heart. Compensatory shock also causes vasoconstriction (the HR to increase) to prevent further loss of fluids. BS are hypoactive and the UO is decreased.

An ECG has been ordered for a newly admitted Veteran. What should the nurse do prior to electrode placement? A. Clean the skin with providone-iodine solution B. Ensure that the area for electrode placement is dry C. Apply tincture of benzoin to the electrode sites and wait for it to become tacky. D. Gently abrade the skin by rubbing the electrode sites with dry gauze of cloth.

D. Gently abrade the skin by rubbing the electrode sites with dry gauze of cloth.

Sepsis is an evolving process, with neither clear defining clinical s/s nor predictable progression. As the ICU nurse caring for a Veteran with sepsis, the nurse knows that tissue perfusion declines during sepsis and the Veteran begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A. UO increases B. Skin becomes warm and dry C. Adventitious lung sounds occur in the upper airway D. Heart and respiratory rates are elevated

D. Heart and respiratory rates are elevated (RAT) Sepsis Assessment: Sepsis can creep up on you, it is an evolving process with no clinical s/s; it can't be predicted it presents with decreased tissue perfusion and organ dysfunction can result. On assessment in the early stage of sepsis, the heart and the respiratory rates are elevated. As sepsis progresses into septic shock the following occurs: Drop in BP HR remains elevated RR remains elevated Pale, cool and mottled skin Decreased UO Adventurous lung sounds throughout. Note: despite the PNS takeover, the HR and RR remain elevated.

How do positive chronotherapy affect the function of the heart? A. Exacerbating an existing dysrhythmia B. Initiating a new dysrhythmia C. Resolving ventricular tachycardia D. Increasing the HR

D. Increasing the HR (RAT) Positive chronotherapy increases the cardiac rhythm by increasing SNS function. The stimulation of the SNS increases the HR, which is known as positive chronotherapy. Definition pg. 712: Chronotropy : is the rate of impulse formation

In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A. It slows the proliferation of bacteria and viruses during shock B. It decreases the energy expended through the functioning of the GI system C. It assists in expanding the intravascular volume of the body D. It promotes GI function through direct exposure to nutrients

D. It promotes GI function through direct exposure to nutrients (RAT) In all types of shock the nurse provides nutritional supplements in the form of enteral nutrition. The body depletes the body's glycogen/energy stores.

The nurse is creating the care plan of an adult Veteran requiring mechanical ventilation. What nursing action is most appropriate? A. Keep the Veteran in a low Fowlers position B. Perform tracheostomy care at least once per day C. Maintain continouse bedrest D. Monitor cuff pressure Q8HRS

D. Monitor cuff pressure Q8HRS (RAT) Mechanical Ventilation Nursing Care Planning for Mechanical Ventilation includes the following: Priority goal in care planning is to monitor the cuff pressure every 8 hours. Why? Because the cuff pressure should be monitored every 8 hours. Perform trach care every 8 hours. Why? the patient is at risk for infection. Education/Teaching: Encourage the patient, "hey you, ambulate as tolerated." Why? To mobilize those secretions.

When caring for a Veteran in shock, one of the major nursing goals is to reduce the risk that the Veteran will develop complications of shock. How can the nurse best achieve this goal? A. Provide a detailed diagnosis and plan of care in order to promote the Veterans and families coping. B. Keep the MD appointment updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C. Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on BP and kin temperature. D. Understand the underlying causes/actions of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

D. Understand the underlying causes/actions of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.