Final 21707
Tracheomalacia
The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication?
Prolonged immobility; advancing age; recent surgery.
A 65-year-old woman is brought to the ED by her husband with new-onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up. What risk factors are present for VTE?
Serum amylase, 200 U/L
A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has "eaten and drunk quite a bit." He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis.
•Malaise
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
•Preventing aspiration
A client has esophageal cancer. Which intervention by the nurse takes priority?
Gloves should be worn whenever direct contact with the client's skin is required.
A client has syphilis with sores present. What precautions are necessary for the nurse to take when caring for this client?
•Bleeding esophageal varices
A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for?
•"I will elevate my arm on a pillow at night."
A client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding of managing this problem?
•"It compresses the urethra, blocking the flow of urine."
A client with BPH asks why his enlarged prostate is causing difficulty with urination. Which is the nurse's most accurate response?
•These results may indicate prostate cancer. He should be further evaluated.
A client's laboratory findings reveal a high prostate-specific antigen level. How does the nurse interpret this information?
•Cloudy CSF, elevated protein
A lumbar puncture is performed on a client suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?
S3 sound
A nurse is assessing a patient with heart failure and auscultates a heart sound right after the second heart sound. How will the nurse document this heart sound?
A.Triglycerides 168 mg/dL B.HDLs 40 mg/dL
A patient has recently been admitted with a diagnosis of coronary artery disease. What lab assessments would the nurse anticipate? (Select all that apply.)
"Smoking is a major risk factor for coronary artery disease and peripheral vascular disease."
A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate?
Administer oxygen via Venturi mask
A patient with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing intervention is most appropriate?
Oxygen at 2 L per nasal cannula
After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour
The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms.
During triage, the following vital signs and assessments are noted Temperature—99.6º F BP—80/44 mm Hg P—126 (sinus tachycardia) R—28 and labored O2 saturation—84% (room air) Crackles bilaterally Petechiae across chest and in axillae Based on these findings, what do you suspect might be happening with the patient?
Pleural effusion Diabetes mellitus Pancreatic infection Acute kidney failure
In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.)
Encourage the patient to sit in a chair for meals.
The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform?
Clear glucose positive fluid draining from nares
The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding requires immediate intervention?
•Absence of bowel movements
The clinic nurse reviews the record of a three-day-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom is most likely led the mother to seek health care for the infant?
•BMI > 30
The nurse assesses the client with cystic fibrosis for all of the following clinical manifestations associated with this disease except:
Ask the patient to lay on his left side.
The nurse is assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate?
•Systolic murmur
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?
•Supine with HOB 30 degrees
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?
•Check the client's gag reflex.
The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action?
•Check the client's blood sugar level.
The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse's priority action?
•Maintaining NPO status for the client with IV fluids
The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client?
. I will give my canned soups to the food pantry
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?
•Heart rate 120 beats/minute
The nurse is getting ready to administer Albuterol inhaler. Which of the following symptoms might indicate a need to contact the healthcare provider before administering this medication?
• "Do not use deodorant on breasts or underarms before the test."
The nurse is preparing a teaching plan for a client who is scheduled to undergo mammography for the first time. What instruction by the nurse is accurate?
•Wear warm clothing when exposed to cool temperatures
The nurse is providing disease management education to a client with Raynaud's disease. What intervention does the nurse suggest to prevent complications if this disease?
•The client is coughing pink, frothy sputum
The nurse is taking care of a client who has experienced a myocardial infarction (MI). The health care provider should be notified when the nurse notes which finding?
•Mask
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?
Chest discomfort when walking and subsiding with rest
The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina?
•Clay-colored stools
The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration?
Weight loss Nasal mask to deliver BiPAP A change in sleeping position Position-fixing device that prevents tongue subluxation
The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.)
•Take medications 45 minutes to one hour before meals
The nurse should instruct the client with myasthenia gravis to
•Client takes naproxen sodium (Naprosyn) 1500 mg daily for arthritis pain.
The nurse us caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion?
Small and frequent meals are best.
The patient has been NPO but is now tolerating food. What education will the nurse provide regarding nutrition?
Respiratory rate
The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F Which vital sign or test result requires the nurse's immediate attention?
-"Be sure to have follow-up INR laboratory tests done." -"Report any bruising or bleeding to your provider." -."Use a soft toothbrush to brush your teeth and an electric razor to shave your legs."
Three days later, the provider prepares to discharge the patient on warfarin (Coumadin). Which teaching points do you include about this therapy? (Select all that apply.)
aPTT is 1.5 to 2.5 times the control.
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol. Which finding indicates that the heparin infusion is therapeutic?
PCA morphine sulfate
When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases. Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time?
•Keep wire cutters readily available at all times.
Which of the following is a priority education for a client who is being discharged after surgical intervention for a mandibular fracture?
Place the patient on a bedpan and stay with her until she is finished.
While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP).
Oxygenate the patient with 100% oxygen
While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?
•Stagnation
You are taking care of 50-year-old client who seems frustrated. He resents his younger counterparts, associates with his family to meet his needs, and is not interested in volunteering in community events. This client is likely experiencing
Pain, especially with inspiration
•The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
•10 seconds
•The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
