MS E4

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. One, some, or all may be correct.

- 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.

While ambulating in the room, a patient reports feeling dizzy. What actions should the nurse take? Select all that apply. One, some, or all may be correct.

- Have the patient sit down in a chair. - Give the patient something to drink. - Take the patient's blood pressure (BP). - Inform the patient's health care provider.

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? Select all that apply. One, some, or all may be correct.

- Monitor serum calcium. -Explain the use of sustained-release opioids. -Support the left leg when repositioning the patient. -Assist family and patient as they discuss the prognosis.

When caring for a preoperative patient on the day of surgery, which actions can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. One, some, or all may be correct.

- Obtain and document baseline vital signs. - Remove nail polish and apply pulse oximeter. - Transport the patient by stretcher to the operating room.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? Select all that apply. One, some, or all may be correct.

- Urinary catheter care - Continuous cardiac monitoring - Administration of H2 receptor blockers - Maintenance of a warm room temperature

Which information should the nurse include when teaching a patient with acute low back pain? Select all that apply. One, some, or all may be correct.

-Expect symptoms of acute low back pain to improve in a few weeks. -Avoid activities that require twisting of the back or prolonged sitting. -Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

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. One, some, or all may be correct.

-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 healthcare provider orders digoxin 0.25 mg IM daily. Available: digoxin 0.5 mg/mL. The nurse will administer mL.

0.5

The healthcare provider orders diltiazem 1 mg/hour. The IV bag has 125 mg of diltiazem in 500 mL. The nurse will set the infusion rate at mL/hour.

4

The healthcare provider orders vasopressin at a rate of 0.3 units/min. The IV bag has 200 units of vasopressin in a 500 mL bag. The nurse will set the infusion rate for mL/hour

45

The healthcare provider orders a dopamine infusion at 4mcg/kg/minute for a client who weighs 165 pounds. Dopamine is provided as 800mg in 250mL D5W. The nurse will set the infusion rate at mL/hour. Round to the nearest whole number.

6

The healthcare provider orders nitroprusside 3 mcg/kg/minute for a client who weighs 187 pounds. Nitroprusside is supplied as 500mg in 250mL D5W. The nurse will set the infusion rate at mL/hour. Round to the nearest whole number

8

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding?

Add additional water to the patient's enteral feedings.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first?

Administer prescribed PRN O2 at 4 L/min.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take?

Allow the family to stay with the patient and briefly explain all procedures to them.

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury?

Apply an immobilizer to the affected leg.

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

Ask about numbness or tingling of the hands and arms.

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Assessment of respiratory rate and effort

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider?

Capillary refill to the fingers is slow.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take

Check the drainage for glucose content.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first?

Check the patient's O2 saturation using pulse oximetry.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

Encourage Immunize for adolescents and college freshman.

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

A client whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the client about correct body mechanics, which client statement indicates the teaching has been effective?

I will begin doing exercises to strengthen and support my back."

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Inform the receiving nurse and then transfer the patient.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider?

Patient has been incontinent of urine and stool.

A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?

Patient who has not voided 8 hours after a laminectomy.

After change-of-shift report, which patient should the progressive care nurse assess first?

Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 second

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?

Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

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 who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

Prepare the patient for craniotomy.

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 prescribed by the health care provider should the nurse implement first?

Provide O2 at 100% per non-rebreather mask.

he home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take?

Provide support to the spouse caregiver.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response?

Respect the patient's feelings and arrange for privacy at mealtimes.

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem?

Risk for infection

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider?

Slow capillary refill of the left foot

A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse report immediately to the health care provider?

Temperature 101.4° F (38.6° C)

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin).

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

The patient reports diffuse chest pressure.

A patient is admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

The patient reports that symptoms began with a severe headache.

Which information in the preoperative patient's medication history is most important to communicate to the health care provider before surgery?

The patient takes garlic capsules every day.

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next?

Verbally coach the patient to breathe with the ventilator.

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). What new finding indicates that the nurse needs to notify the health care provider immediately?

increased jugular venous distention.

Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis?

loss of height

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

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

risk for aspiration

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

triggers leading to facial discomfort.