med surg quiz #4 (chp. 28)
The nurse has just received report on a group of clients. Which client is the nurse's first priority? a) A 45 year old with a peritonsillar abscess who can no longer swallow. b) A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C) c) A 25 year old who had endoscopic sinus surgery 8 hours ago. d) A 55 year old with tuberculosis who is standard first-line therapy.
A 45 year old with a peritonsillar abscess who can no longer swallow. The client at greatest risk for a respiratory complication is the one with a peritonsillar abscess who is no longer able to swallow. This abscess is enlarging and could completely obstruct the client's airway. Rapid assessment is needed immediately to determine the degree of intervention urgency. No other client listed has indications of the need for potential emergency action.
Which client will the nurse recognize as being at risk for bacterial sinusitis? a) A 45 year old with multiple dental caries and infected gums b) A 25 year old with seasonal pollen allergies c) A 65 year old who has a poor gag reflex after a stroke d) 35 year old with a 20-pack-year smoking history who now vapes
A 45 year old with multiple dental caries and infected gums Dental infections of any kind greatly increase the risk for bacterial sinus infection. Smoking and vaping do not increase the risk for sinusitis although they do increase the risk for head and neck cancers. Allergies alone do not increase the risk. A poor gag reflex increases the risk for aspiration pneumonia but not sinusitis.
A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. a) blurry vision b) constipation c) difficulty sleeping d) nausea when drinking beer e) red-tinged urine f) sunburn with minimal sun exposure g) yellowing of the sclera
A, G The drug ethambutol can cause optic neuritis that can lead to blindness. The drug should be stopped and the patient's vision evaluated immediately. Yellowing of the sclera is associated with jaundice from liver problems, which can be serious and life-threatening. The client's liver status must be evaluated immediately. Although nausea when drinking alcohol is an expected side effect of ethambutol, it is a priority to report this change to the health care provider at this time. The nurse needs to explain the side effect to the client and remind him or her that alcohol must be avoided during TB therapy to prevent liver problems. This change only needs to be reported to the health care provider if the client continues to consume alcohol. Difficulty sleeping may or may not be associated with the TB drug therapy. It does not require immediate attention. Red-tinged urine is an expected side effect of rifampin. The nurse reinforces this information to the client to relieve his or her anxiety. The drug pyrazinamide increases photosensitivity. Sunburn is a common side effect that the nurse needs to instruct the client to prevent but does not require immediate attention from the healthcare provider.
Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? a) high fever b) profound bradycardia c) acute confusion d) coughing spasms
Acute confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Tachycardia is triggered by hypoxia, not bradycardia.
Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? a) administer oxygen to prevent hypoxemia and atelectasis b) administer the prescribed bronchodilator therapy to decrease bronchospasms c) encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration d) maintain semi-Fowler position to facilitate breathing and prevent further fatigue
Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.
Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? a) Arranging for a health care worker to directly observe the client take the drugs b) Giving the client written instructions about how and when to take the drugs c) Instructing the client about the consequences of not taking the drugs d) Having the client repeat the drug names and side effects
Arranging for a health care worker to directly observe the client take the drugs The most effective action for the nurse to take to ensure that the client complies with the treatment regimen is to arrange for the client to be directly observed during therapy. The heroin addiction reduces the client's likelihood of adherence to long-term treatment unless closely supervised while taking the drugs.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Even if the client can state the names and side effects of the drugs does not indicate understanding of the importance of this therapy.
A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "She had one 2 years ago and doesn't need another." What is the nurse's best response? a) "your mother is older now and is more fragile, so she should have one this year, too, as a booster." b) "the virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." c) "the "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." d) "if you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."
B A is incorrect because each year's influenza vaccine is composed of some different strains of antigen and is not really a booster. C is incorrect because the older vaccination may not contain the viral antigens most likely to cause influenza this season. The nasal mist vaccination is not recommended for anyone over age 49 years.
A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? a) encourage the client to use the incentive spirometer hourly b) increase her O2 flow rate by 2 L and reassess in 5 minutes c) increase the flow rate of the IV antibiotics d) document the changes as the only action
B The low oxygen saturation and the client's confusion suggests hypoxia and a possible worsening of the client's condition. The increased respiratory rate supports this possibility. Increasing the oxygen flow rate and re-assessing in 5 minutes helps the nurse to determine whether the hypoxia responds to increased oxygen. If more oxygen is going to help, it will do so quickly. Even if the oxygen saturation increases with more oxygen, the health care provider needs to be informed of these events urgently. The incentive spirometer is not likely to be performed correctly with a confused client and would not immediately improve the client's hypoxia. Increasing the flow rate of the antibiotic also is not going to help the hypoxia immediately.
Which adults are at higher risk for development of active tuberculosis? Select all that apply. a) 21-year-old college student living in a dorm at a Canadian university b) 38-year-old with HIV-II (AIDS) who stopped taking antiretroviral therapy c) 42-year-old injection drug user d) 50-year-old Guatemalan migrant farm worker e) 62-year-old incarcerated in prison for 20 years f) 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)
B, C, D, E Active tuberculosis is most likely to develop in adults who are heavily exposed to the organism, such as those living in crowded conditions (prison), from less affluent foreign countries, and anyone who is immunosuppressed (has AIDS and is not taking antiretroviral therapy). Adults who use/abuse injection drugs are also at increased risk because of life style and reduced cognition while under the influence of the drugs. This can result in choices that increase his or her exposure to the organism and may reduce immunity. A healthy 21-year-old living in a dorm in an affluent country is not at increased risk for TB. Having moderate to severe COPD alone does not increase risk for TB unless immunity is greatly reduced.
The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F. What is the nurse's primary concern for this client? a) the client may not be taking the prescribed antiviral drug correctly b) a second strain of influenza is likely c) pneumonia may be present d) the client may be dehydrated
C A major and relatively common complication of severe seasonal influenza is development of pneumonia. It is likely this client's influenza was severe because hospitalization was required. The client would no longer be receiving the antiviral drug after discharge. A second strain of influenza is not likely in this context. Temperature elevation from dehydration is usually less dramatic.
A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? a) "No, going out now before you have recovered your strength can cause a relapse of the pneumonia" b) "No, the risk that you could spread this disease to other people is much too high." c) "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." d) "Yes, if you agree to wear a face mask to prevent spreading droplets."
C The client is no longer contagious after completing the course of antibiotics and is just in the recovery phase of the illness. If he feels rested enough to be up in a wheel chair, there is no reason he must be isolated physically or socially. A face mask is not needed to protect others.
Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? a) chest tightness and SpO2 of 86% b) productive cough and yellow-colored sputum c) anorexia and weight loss d) intermittent fever and sweating
Chest tightness and SpO2 of 86% Symptoms of COVID-19 are similar to those of seasonal asthma. However, the inflammatory responses occurring in the lungs with serious COVID-19 infection causes lung stiffness with chest tightness and greatly reduced gas exchange. The other symptoms are not specific to COVID-19 or other pandemic respiratory infections.
Which drug will the nurse expect to teach about to a client who has been exposed to inhalation anthrax but does not have symptoms? a) Vancomycin b) Oseltamivir c) Rifampin d) Ciprofloxacin
Ciprofloxacin The most recommended drug therapy for prophylaxis after exposure to inhalation anthrax is oral ciprofloxacin. Vancomycin is an intravenous drug used for treatment of actual anthrax infection. Oseltamivir is an antiviral agent, and rifampin is a first-line drug for treatment of tuberculosis.
Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? a) client has been afebrile for 48 hours b) oxygen saturation ranges between 90% and 92% on room air c) white blood cell count is 16, 000 cells/mm3 (16 × 109/L) d) bronchial breath sounds present in lung periphery
Client has been afebrile for 48 hours. A positive outcome is indicated by the client having been afebrile for 48 hours.Bronchial breath sounds in lung peripheral areas are abnormal. The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The listed count is elevated and indicates continuing infection. The normal oxygen saturation is expected to be above 95%.
Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) a) Continuous nasogastric (NG) tube feedings b) Bronchoscopy procedure c) Decreased level of consciousness d) Magnetic resonance imaging (MRI) procedure e) Stroke f) Chest tube
Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Decreased level of consciousness Stroke The risk for aspiration pneumonia is increased whenever the client has a reduced or absent gag reflex (e.g., decreased level of consciousness, stroke, following local anesthesia for a bronchoscopy procedure), and when a client's lower esophageal sphincter does not close complete. This situation occurs when an NG tube is in place, preventing complete or tight constriction of the sphincter.
Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? a) assessing the need for an immediate dose of lorazepam b) requesting a referral to a social worker for alcohol counseling c) drawing blood for aerobic and anaerobic blood cultures d) administering intravenous antibiotics
Drawing blood for aerobic and anaerobic blood cultures The nurse will first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed to identify the specific causative organism. Initiating antibiotic therapy before cultures are obtained could affect the results of the culture and possibly delay identification an antibiotic more for the infection. Thus, antibiotic therapy is started after blood for cultures is obtained.Unless this client is a danger to self or staff, giving lorazepam for agitation is not the first action. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.
Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? a) productive cough and normal temperature b) flushed cheeks and increased respiratory rate c) hypotension and rapid, weak pulse d) SpO2 of 86% and confusion
Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.
What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? a) Increasing the flow rate of the IV piggy-back antibiotic b) Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes c) Assisting the client to a more upright position d) Reporting the change in status to the client's primary health care provider
Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes The client is becoming increasingly hypoxemic and needs more supplemental oxygen. After oxygen delivery is increased, the nurse will determine the client's response to this action.Although moving the client to a more upright position is not harmful and can increase oxygenation, it is not as effective in managing hypoxemia as increasing the oxygen flow rate. It should be the second action, not the first. Although the pneumonia may be worsening, giving the IV antibiotic at a faster rate is not going to make an immediate difference. In addition, infusing it faster may increase the risk for side effects and adverse effects. Before notifying the primary health care provider, the nurse will assess the client's response to increased oxygen flow rate. If the oxygen saturation has not improved or has decreased further in 5 minutes, the nurse would then immediately notify the primary health care provider.
Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? a) tuberculosis b) pneumonia c) emphysema d) heart failure
Pneumonia Pneumonia is the most common complication of seasonal influenza, especially among older clients. The symptoms of pneumonia include fever that does not resolve and acute confusion.Although heart failure is a complication of pneumonia, it is less common and not accompanied by fever. Neither emphysema nor tuberculosis is a complication of seasonal influenza.
Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? a) starting an IV line to begin hydration therapy b) administering IM influenza vaccination c) asking the client when symptoms began d) placing the client in a negative air pressure room
Starting an IV line to begin hydration therapy The nurse's first priority is to start an IV line and begin intravenous hydration to maintain perfusion. Older clients with influenza symptoms can develop dehydration quickly because of fever, vomiting, and possible diarrhea. Asking when the symptoms first started is not important. A negative airflow room is not required and is usually in short supply. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority because it takes weeks for full immunity to develop.
Which action to prevent harm has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? a) Be sure to drink at least 2 L of fluids daily. b) Take these drugs daily exactly as prescribed. c) Expect a change in urine color. d) Wear use sunscreen and wear protective clothing when you are out-of-doors.
Take these drugs daily exactly as prescribed. The most important action is to take the drugs as prescribed to be effective and to prevent development of drug-resistant tuberculosis organisms. One drug in the regimen does change urine to a reddish color, but this is harmless. Two other drugs cause some degree of photosensitivity and increase the risk for sunburn; however, this is not a reason to stop the therapy.
Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) a) Those who were treated previously for active tuberculosis b) Kidney transplant recipients c) Homeless adults d) Those who have received bacille Calmette-Guérin (BCG) vaccine e) Those in the local prison f) Recent immigrants to the United States
Those who were treated previously for active tuberculosis Kidney transplant recipients Homeless adults Those in the local prison Recent immigrants to the United States Adults who are at highest risk for TB include those who live in crowded areas such as prisons and homeless shelters, those who are recent immigrants to the United States, those who are taking long-term immunosuppressive agents, and those who have already had active TB.Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.
What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? a) performing oral care before, as well as after, suctioning the oropharynx b) wearing a disposable particulate mask N95 respirator with face shield or goggles c) washing hands and donning gloves prior to the procedure d) keeping the door to the client room closed
Wearing a disposable particulate mask N95 respirator with face shield or goggles The most important infection control precaution the nurse must take before suctioning a client with any pandemic influenza is to wear a particulate mask respirator with protective eyewear or a face shield to prevent infectious organisms from entering the nurse's mucous membranes and respiratory tract.The door to the room needs to be closed during any care of the client with a pandemic influenza. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.
