Chapter 14,66,69 MED SURG 2

A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

Auscultate breath sounds

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming?

The core temperature is 94° F (34.4° C).

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider?

The patient is complaining of chest pain

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT).

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin.

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?

The patient's IV infusion site is cool and pale.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?

Warm, pink, and dry skin

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to

assess the patient's current vital signs

When planning the response to the potential use of smallpox as a biological weapon, the emergency department (ED) nurse manager will plan to obtain adequate quantities of

vaccine.

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

"Can you tell me more about the thoughts that you are having?"

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

"Consider participating in a needle-exchange program."

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?

"Do you feel safe at home?"

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?

"I need to drink extra fluids when working outside in hot weather."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

"The patient has developed acquired immunodeficiency syndrome (AIDS)."

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?

"You will need to be retested in 2 weeks."

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to

. apply wet sheets and a fan to the patient.

A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?

27

The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].)

A 21-yr-old patient with multiple fractures of the face and jaw,A 74-yr-old patient with palpitations and chest pain,A 43-yr-old patient complaining of 7/10 abdominal pain,A 37-yr-old patient with a misaligned lower left leg with intact pulses

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

A patient with a red tag

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?

A patient with paradoxical chest movement

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)?

Ambulate postoperative patients as soon as possible after surgery., Use aseptic technique when manipulating invasive lines or devices,Remove indwelling urinary catheters as soon as possible after surgery.,Administer prescribed antibiotics within 1 hour for patients with possible sepsis

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?

Administer furosemide (Lasix) 40 mg IV.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

Age

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

Skin cool and clammy

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?

Antibiotics may sometimes be prescribed to prevent infection., Continue taking antibiotics until all of the prescription is gone,Hand washing is effective in preventing many viral and bacterial infections

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?

Ask the family members whether they would prefer to remain in the patient's room or wait outside the room

Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply)?

Assist with endotracheal intubation., Insert an indwelling urinary catheter.,Begin continuous cardiac monitoring.

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Assist with intubation of the patient.

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?

Brush off any visible powder on the skin and clothing.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

Check stools for occult blood.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?

Discuss a change in antiretroviral therapy.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

Explain to the patient that this is an expected finding

A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

Give N-acetylcysteine.

The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

Give acetaminophen (Tylenol) 650 mg., Place cooling blankets above and below patient.,Attach rectal temperature probe to cooling blanket control panel

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?

Give epinephrine

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Give normal saline IV at 500 mL/hr

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

Heart rate 45 beats/min

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?

Hepatitis B vaccine, Pneumococcal vaccine, Influenza virus vaccine

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

Increase the rate for the sodium nitroprusside infusion

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question?

Infuse normal saline at 250 mL/hr

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?

Initiate cooling per protocol

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?

Maintaining a cool room temperature for a patient with neurogenic shock

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

Monitor breath sounds frequently.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used for a venipuncture

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?

New onset of confusion

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

Observe the patient's respiratory effort.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

Oral saquinavir (Invirase)

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?

Oxygen saturation

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

After change-of-shift report in the progressive care unit, who should the nurse care for first?

Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?

Platelet count and presence of petechiae

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)?

Prepare to administer atropine IV., Obtain baseline body temperature.Provide high-flow O2 (100%) by nonrebreather mask., Prepare for emergent intubation and mechanical ventilation

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?

Provide O2 at 100% per non-rebreather mask.

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?

Pulse

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Remove the patient's rings.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next?

Start normal saline fluid infusion with a large-bore IV line.

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patient's room with the necessary personal protective equipment.

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving

TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

Teach the patient the reason for the use of prophylactic antibiotics

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

The patient's central venous pressure is 3 mm Hg.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

The patient's serum creatinine level is elevated.

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)

Titrate oxygen administration to keep O2 saturation above 95%,Infuse normal saline 2000 mL over 30 minutes,Start norepinephrine 0.5 mcg/min.,Obtain blood and urine cultures,Give vancomycin 1 g IV.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

Urine output is 65 mL over the past hour

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?

Use tweezers to remove any remaining ticks.

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of

abdominal ultrasonography

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

administer supplemental oxygen

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

c. Remind the patient about the need to return for retesting to verify the results.

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?

furosemide (Lasix) IV

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)?

gowns, gloves

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

norepinephrine .

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should

obtain a Glasgow Coma Scale score

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain

two 16-gauge IV catheters.