vSim - Bronson and Hughes
The patient experiencing an anaphylactic reaction may experience which of the following signs and symptoms? (Select all that apply.) a) Dyspnea b) Pruritus c) Bronchospasm d) Laryngeal edema e) Pallor
a) Dyspnea b) Pruritus c) Bronchospasm d) Laryngeal edema Mild systemic reactions consist of peripheral tingling, warmth, a sensation of fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes. Moderate systemic reactions may include flushing and anxiety in addition to any of the milder symptoms. More serious reactions include bronchospasm, laryngeal edema, severe edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.
When a patient presents to the emergency department with pneumonia, which signs and symptoms would the nurse expect to exhibit? (Select all that apply.) a) Fatigue b) Orthopnea c) Fever d) Night sweats e) Dyspnea
a) Fatigue b) Orthopnea c) Fever e) Dyspnea Fever is present with the infection. Patients with exhibit dyspnea, preferring to be propped up or sitting up due to orthopnea (SOB when reclining or supine). The patient is fatigued from the work of breathing.
Which of the following represent initial signs and symptoms of a patient in respiratory distress? (Select all that apply.) a) Hypoxemia b) Cyanosis c) Dyspnea d) Fever e) Tachypnea
a) Hypoxemia c) Dyspnea e) Tachypnea Dyspnea and tachypnea accompanied by low oxygen in the blood are associated with respiratory distress. Cyanosis is a very late indicator of hypoxia to the tissues. Fever is an indication of infection.
The nurse is aware that a late sign of compartment syndrome is which of the following? a) Motor weakness b) Unrelenting pain c) Burning sensation d) Sluggish capillary refill
a) Motor weakness Motor weakness may occur as a late sign of nerve ischemia. Unrelenting pain and a burning sensation are early signs. A sluggish capillary refill indicates early there is decreased blood perfusion.
Vital signs received during report on Ms. Hughes were BP: 130/82, HR: 88, RR: 16. During the initial assessment, vital signs were BP: 150/90, HR: 100, RR: 20, SpO2 98%. What is the most likely cause for the elevation in vital signs? a) Pain b) Hypoxemia c) Morphine d) Bleeding
a) Pain Pain will cause an increase in vital signs. Bleeding will cause a decrease in BP and increase in pulse. Opioids will decrease BP and RR. Hypoxemia was not present; the SpO2 was within the normal range.
The nurse understands that surgical fixation of fractures carries a risk of infection. The nurse monitors for which of the following signs and symptoms of infection? (Select all that apply.) a) Pain b) Redness c) Elevated white blood cell count d) Elevated temperature e) Decreased hemoglobin f) Swelling
a) Pain b) Redness c) Elevated WBC d) Elevated temperature f) Swelling The symptoms of infection include tenderness, pain, redness, swelling, local warmth, elevated temperature, increased WBC, and purulent drainage. Decreased hemoglobin is a sign of bleeding.
A nurse is aware that compartment syndrome can occur when which of the following happen? a) Perfusion pressure falls below tissue pressure distal to an injury b) Blood flow surrounding the area of injury gradually decreases c) Perfusion rises above tissue pressure proximal to the injury d) Blood flow distal to the injury suddenly increases
a) Perfusion pressure falls below tissue pressure distal to an injury Compartment syndrome occurs when increased pressure within a confined space compromises blood flow and low tissue perfusion occurs. Ischemia and potentially irreversible neuromuscular damage can occur if action is not taken.
What risk factor does the nurse recognize that Kenneth Bronson had related to pneumonia? a) Smoking b) Hay fever c) Influenza d) Asthma
a) Smoking Smoking is a risk factor for pneumonia; cigarette smoke disrupts both mucociliary and macrophage activity. Although staphylococcal pneumonia has been noted after epidemics of influenza, Kenneth Bronson did not have this particular risk factor.
The nurse understands that which of the following is a hallmark sign of compartment syndrome? a) Decreased sensation of extremity b) Pain that intensifies with passive range of motion c) Skin color changes d) Extremity firm to palpation
b) Pain that intensifies with passive ROM Clinical manifestations of compartment syndrome include dusky, pale appearance of the exposed extremity; cool skin temp; delayed cap refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. However, a hallmark sign of compartment syndrome is pain that occurs or intensifies with passive ROM (e.g., pain intensifies with dorsiflexion of the wrist of the affected extremity).
The nurse understands that assessing neurovascular function in a patient with a brace, splint, or cast is vitally important. Neurovascular assessment findings that indicate neurovascular compromise include which of the following? (Select all that apply.) a) Proprioception b) Paresthesia c) Paralysis d) Pallor e) Pronation
b) Paresthesia c) Paralysis d) Pallor The "5Ps" indicative of symptoms of neurovascular compromise are pain, pallor, pulselessness, paresthesia, and paralysis.
Epinephrine is administered for Kenneth Bronson's acute anaphylactic reaction. Which of the following does the nurse know is a possible side effect of this drug? a) Bradycardia b) Tachycardia c) Bradypnea d) Flushed skin
b) Tachycardia Tachycardia is one possible CV adverse effect of epinephrine.
Is the following statement true or false? The morphine administered to Ms. Hughes was not effective in relieving her pain; this is a sign of potential compartment syndrome. a) False b) True
b) True Patients with compartment syndrome may complain of deep, throbbing, unrelenting pain, which continues to increase despite the administration of opioids and seems out of proportion to the injury.
The nurse should include which statement when providing education once the patient is first stabilized after an anaphylactic reaction? a) "You will be intubated and put on a ventilator to protect your airway." b) "You will be discharged when the preloaded syringe of epinephrine is available for you to take home." c) "You will be closely monitored since there is a chance of a delayed reaction." d) "You will require oxygen for a few days."
c) "You will be closely monitored since there is a chance of a delayed reaction." The patient requires continued observation and monitoring because of the risk for a "rebound" or delayed immune reaction. The patient will not be immediately discharged once stable. Patients who have experienced an anaphylactic reaction should receive a Rx for preloaded syringes of epinephrine. Oxygen therapy is individualized and based on SpO2 levels and blood gases. Intubation is not mandated if the patient's respiratory status is stable.
What assessment findings observed by the nurse would demonstrate poor vascular perfusion to a splinted extremity? (Select all that apply.) a) Oxygen saturation of 93% b) Warm, reddened toes c) Decreased pedal pulses d) Blood pressure of 110/70 e) Pale foot
c) Decreased pedal pulses e) Pale foot Poor arterial perfusion and venous congestion would cause a decrease in pulses and cold, dusky or blue-tinged discoloration of toes. The blood pressure is within normal range. The oxygen saturation represents the oxygen bound to hemoglobin and not perfusion.
Which of the following can reduce the incidence of fat embolism and shock as complications from a bone fracture? a) Ice packs to extremity b) Adequate nutrition c) Early surgical fixation d) Oxygen therapy
c) Early surgical fixation Stabilization of the fracture with surgical fixation reduces the incidence of bleeding and fat emboli. Application of ice packs assists in the reduction of edema. Proper nutrition enhances fracture healing. Oxygen therapy is an intervention used when respiratory compromise occurs with the complications.
The nurse is assessing the lungs of a patient diagnosed with pneumonia. Which of the following would be expected upon auscultation? (Select all that apply.) a) Wheezes b) Absent breath sounds c) Egophony d) Bronchial breath sounds
c) Egophony d) Bronchial breath sounds Bronchial breath sounds occur in consolidation, such as pneumonia. Egophony may occur in patients diagnosed with pneumonia. Absent breath sounds occurs in pneumothorax. Wheezes are associated with bronchial wall oscillation and changes in airway diameter.
Upon initial assessment of the patient's limb in this scenario, the nurse determines the first priority is to do which of the following? a) Apply warm compresses b) Continue to monitor the affected extremity c) Notify the provider immediately d) Encourage ambulation
c) Notify the provider immediately The provider must be notified immediately so appropriate treatment may be initiated and permanent damage prevented. Ms. Hughes was expressing extreme pain with no relief from recent morphine injection. This condition is an emergency because the sudden decrease in blood flow in compartment syndrome can result in ischemic necrosis if prompt intervention does not occur immediately.
What neurovascular assessment finding would cause the nurse to suspect compartment syndrome? a) Bounding pedal pulse on affected side b) Heightened sensation at the fracture site c) Numbness and/or tingling of affected extremity d) Localized, reddened area on calf
c) Numbness and/or tingling of affected extremity With continued nerve ischemia and edema, with patient experiences sensations of hypoesthesia (diminished sensation followed by complete numbness).
When monitoring for potential in the patient with a cast, splint, or brace, the nurse recognizes which of the following is an early hallmark sign of compartment syndrome? a) Sharp, knifelike pain b) Absence of pain c) Pain that intensifies with passive range of motion d) Intermittent pain in the extremity
c) Pain that intensifies with passive ROM A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive ROM due to accumulation of fluid within the compartmental space.
After assessing the patient, the nurse recognizes what the cause of compartment syndrome is Ms. Hughes' case is most likely related to which of the following? a) An internal hemorrhage b) The nature and location of the fracture c) The restrictive splint dressing d) Lack of mobility and range of motion
c) The restrictive splint dressing Compartment syndrome occurs when increased pressure within a confined space compromises blood flow and low tissue perfusion occurs. Tight casts or constrictive splints are often the cause of this complication. In Ms. Hughes' case, when the splint is loosened, perfusion to the extremity is assessed as improved.
The nurse is auscultating lung sounds. What lung sound is associated with narrowing of the airway? a) Egophony b) Crackles c) Wheezes d) Bronchophony
c) Wheezes Wheezing is a high-pitched, musical sound associated with airway narrowing. Crackles are described as a popping sound heard during inspiration from fluid or delayed opening of collapsed alveoli. Bronchophony or egophony can be auscultated when there is increased lung density from pneumonia and pulmonary edema.
When a patient develops respiratory distress, what is the appropriate first action for the nurse to take to address this specific concern? a) Begin manual ventilation and applied oxygen b) Perform a cardiac assessment and ask for a detailed history from the patient c) Apply oxygen and lower the head of the bed d) Assess airway, breathing, circulation, and auscultate the lungs
d) Assess airway, breathing, circulation, and auscultate the lungs When a patient is in respiratory distress, it is important to determine the cause so appropriate measures to treat the patient can be started. Assessing the airway, breathing, and circulation are the basic first steps. Auscultating the lungs help to further delineate what the potential cause and treatment will be.
The nurse suspects that a patient may be developing compartment syndrome. The nurse knows that, for compartment syndrome, the limb should be maintained in which of the following positions? a) Position of comfort b) Above heart level c) Below heart level d) At heart level
d) At heart level The extremity should be elevated but no higher than heart level to maintain arterial perfusion and prevent further fluid accumulation in the compartment/affected limb.
A patient experiencing respiratory distress at home from pneumonia is brought to the hospital and upon presentation requires intubation. How would the nurse classify this type of pneumonia? a) Hospital-acquired pneumonia b) Ventilator-associated pneumonia c) Health-care-associated pneumonia d) Community-acquired pneumonia
d) Community-acquired pneumonia Community-acquired pneumonia (CAP) is pneumonia occurring in the community or within less than 48 hours of hospital admission. Health-care-associated pneumonia (HCAP) occurs in a non-hospitalized patient with extensive health care contact. Hospital-acquired pneumonia (HAP) occurs 48 hours or more after hospital admission. Ventilator-associated pneumonia (VAP) is a type of HAP that develops 48 hours or more after intubation.
Which of the following is used to intravenously to maintain blood pressure in a patient experiencing hypotension during an anaphylactic reaction? (Select all that apply.) a) Dextrose 5% b) Aminophylline c) Albuterol d) Epinephrine e) Normal saline
d) Epinephrine e) Normal saline A bolus of normal saline is given for hypotension. An epinephrine IV drip will increase BP. Dextrose is not given as a bolus. Aminophylline and albuterol are bronchodilators.
The nurse is aware that if conservative measures do not relieve pain and restore tissue perfusion, the patient will need which of the following emergency treatments to correct compartment syndrome? a) Debridement b) Incision and drainage c) Myotomy d) Fasciotomy
d) Fasciotomy If the initial steps of loosening the cast or splint and elevation of the limb to the level of the heart do not relieve the pressure and pain and restore circulation, then a fasciotomy may be necessary to relieve the pressure within the muscle compartment and prevent neurovascular damage.
Which medication was administered to Mr. Bronson to decrease inflammation? a) Acetaminophen b) Epinephrine c) Albuterol d) Methylprednisolone
d) Methylprednisolone Methylprednisolone is a corticosteroid used to decrease inflammation. Albuterol and epinephrine cause bronchodilation. Acetaminophen is used to treat the fever from pneumonia.
The nurse understands that which of the following is the most common cause of anaphylaxis? a) NSAIDs b) Opioids c) Radiocontrast agent d) Penicillin
d) Penicillin Penicillin is the most common cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the US each year. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Opioids, NSAIDs, and radiocontrast agents are some of the medications that are frequently reported as causing anaphylaxis.
Once the patient is stabilized after an anaphylactic reaction, what information would be most essential for the nurse to include with patient and family follow-up teaching? a) The rationale for oxygen therapy b) The pathophysiology of pneumonia c) Deep breathing and coughing techniques d) What caused the event and how to prevent an anaphylactic reaction
d) What caused the event and how to prevent an anaphylactic reaction It will be important for the patient and family to know what caused the anaphylactic reaction and how to prevent it from happening in the future. They should also receive instruction on the proper use of a preloaded epinephrine syringe.
When monitoring for potential complications after surgery, what finding would cause the nurse to suspect that the patient is experiencing postoperative bleeding? a) Increase in WBC count b) Decrease in hemoglobin c) Increase in hematocrit d) Decrease in creatinine
b) Decrease in hemoglobin The decrease in hemoglobin would suggest bleeding. Hematocrit would also decrease. An increase in WBC count indicates infection. Bleeding and decrease in intravascular fluid volume would cause an increase in creatinine from decreased blood volume to the kidneys.
The nurse understands that neurovascular assessments should be performed how frequently during the first 24 hours following application of an immobilization device to a fractured extremity? a) Every shift b) Every hour c) Every 4 hours d) Daily
b) Every hour A major nursing concern following the application of an immobilization device is hourly assessment of the extremity during the first 24 hours and every 1-4 hours thereafter to prevent neurovascular dysfunction or compromise from edema or a constricting immobilization device.
Which of the following are appropriate initial nursing interventions to control discomfort in a fractured extremity stabilized with a splint or cast? (Select all that apply.) a) Analgesic medication b) Intermittent cold packs c) Elevation of extremity d) Warm compression e) Lowering of extremity
a) Analgesic medication b) Intermittent cold packs c) Elevation of extremity Pain caused by edema can be reduced in the fractured extremity that has normal neurovascular checks by using intermittent cold packs and elevating the extremity. An analgesic medication is ordered to control pain. Warm compresses and lowering of the extremity can increase edema and pain.
The nurse administering diphenhydramine understands that the medication falls under which of the following categories for the treatment of an anaphylactic reaction? a) Antihistamine b) Bronchodilator c) Vasopressor d) Antipyretic
a) Antihistamine Diphenhydramine (Benadryl) is an antihistamine used to block the histamine released in the immune response with anaphylaxis.
What is the priority action by the nurse when a patient experiences sudden respiratory distress? a) Assess the airway b) Lower the head of the bed c) Call the provider d) Place an intravenous line
a) Assess the airway The priority action it to assess the airway. Raising the head of the bed will improve lung expansion. The provider should be notified and IV line may be needed, but assessing the patient is the priority.