AH2 - Exam 1

DPOAHC (Durable power of attorney)

A legal document in which a person appoints someone else to make health care decisions in the event he or she becomes incapable of making decisions.

Living Will

A legal document that instructs health care providers and family members about what life-sustaining treatment is wanted (or not wanted) if the patient becomes unable to make decisions.

Tension Pneumothorax

A life-threatening complication of pneumothorax in which air continues to enter the pleural space during inspiration and does not exit during expiration.

CRBSI bundle

A nationally recognized set of evidence-based practices to prevent CRBSIs. -Proper aseptic hand hygiene -Measuring upper arm circumference as a baseline before insertion -Maximal barrier precautions on insertion -Chlorhexidine skin antisepsis -Optimal catheter site selection and post-placement care with avoidance of the femoral vein for central venous access in adult patients -Daily review of line necessity with prompt removal of unnecessary lines

acute respiratory distress syndrome (ARDS)

A type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury as a result of other conditions such as sepsis, burns, pancreatitis, trauma, and transfusion.

Advanced Directive (AD)

A written document prepared by a competent person to specify what, if any, extraordinary actions he or she would want when no longer able to make decisions about personal health care.

A nurse teaches a client who is being discharged home with a peripherally inserted center catheter (PICC). Which statement will the nurse include in this client's teaching? A. "Avoid carrying your grandchild with the arm that has the central catheter." B. "Be sure to place the arm with the central catheter in a sling during the day." C. "Flush the peripherally inserted central catheter line with normal saline daily." D. "You can use the arm with the central catheter for the most activities of daily living."

A. "Avoid carrying your grandchild with the arm that has the central catheter." A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most ADLs, however, heavy lifting can dislodge the catheter or occlude the lumen. The device is flushed with heparin.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? A. Assess for other manifestations of hypoxia. B. Change the sensor on the pulse oximeter. C. Obtain a new oximeter from central supply. D. Tell the client to take slow, deep breaths.

A. Assess for other manifestations of hypoxia. Pulse ox is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more through assessment. The other actions are not appropriate for a hypoxic client.

For which purpose would the nurse offer massage therapy to the dying patient? SATA A. Decrease pain B. Enhance dignity C. Decrease nausea D. Promote relaxation E. Reduce the need for analgesics

A. Decrease pain B. Enhance dignity D. Promote relaxation

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch venous cord. How will the nurse document this finding? A. Grade 3 phlebitis at IV site B. Infection at IV site C. Thrombosed area at IV site D. Infiltration at IV site

A. Grade 3 phlebitis at IV site

Which patient statement regarding durable power of attorney for health care (DPOAHC) indicates a need for further teaching? A. It is the same as durable power of attorney (DPOA) for financial affairs B. It is referred to as health care proxy, health care agent, or surrogate decision maker C. It allows the individual to make a decision only is the patient become cognitively impaired D. It requires the decision make to receive information, evaluate, deliberate, and communicate a treatment preference.

A. It is the same as durable power of attorney (DPOA) for financial affairs

Which statement accurately describes active euthanasia? A. It may be voluntary or involuntary B. Nurses are required to be involved in the procedure C. Most professional health organizations support it D. The action intended to have a good effect also has a harmful effect.

A. It may be voluntary or involuntary

The hospice nurse is caring for an older patient with prostate cancer. Which patient behavior would the nurse expect as a common emotional sign of approaching death? SATA A. Letting go B. Withdrawal C. Saying goodbye D. Feelings of anxiety E. Restlessness and agitation

A. Letting go B. Withdrawal C. Saying goodbye

For which condition of a dying patient would the nurse take action? A. Moaning B. Anorexia C. Cool Extremities D. Alternating apnea and rapid breathing

A. Moaning Moaning indicates pain and requires pain medication.

Which indication of discomfort may the nurse observe when the patient with an end-stage terminal illness is asleep? SATA. A. Moaning B. Grimacing C. Restlessness D. Talking during sleep E. Breathing pattern changes

A. Moaning B. Grimacing C. Restlessness

A dying patient who cannot swallow is accumulating audible mucus in the upper airway. The nursing assistant reports that these noises are upsetting to family members. Which instruction would the nurse give to the assistant? A. Place the patient in a side-lying positions so secretions can drain B. Position the patient in high-Fowler position to minimize secretions C. Ask the family to leave the room so they can compose themselves D. Use a Yankauer suction tip to remove secretions from the patient's upper airway

A. Place the patient in a side-lying positions so secretions can drain

Which condition is typical cause of nausea and vomiting in a terminally ill patient during the last week of life? SATA A. Uremia B. Hypocalcemia C. Stool impaction D. Bowel obstruction E. Reduced cranial pressure

A. Uremia C. Stool impaction D. Bowel obstruction A bisphosphate enema or mineral oil enema followed by gentle disimpaction may help relieve the patient's distress

Pneumothorax

Air in the pleural space causing a loss of negative pressure in the chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse.

Adverse Drug Event (ADE)

An unintended harmful reaction to an administered drug

Which intervention would the nurse use to help relieve dyspnea for a dying patient who has loud, wet respirations? SATA A. Monitor vitals to assess for infections B. Administer atropine solution 1% sublingually C. Place a small towel under the patient's mouth D. Reposition the patient to one side of the hospital bed E. Perform oropharyngeal suctioning to clear the secretions

B. Administer atropine solution 1% sublingually C. Place a small towel under the patient's mouth D. Reposition the patient to one side of the hospital bed

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? A. Begin the prescribed infusion via the new access. B. Ensure that an x-ray is completed to confirm placement. C. Check medication calculation with a second RN. D. Make sure that the solution is appropriate for a central line.

B. Ensure that an x-ray is completed to confirm placement. A central venous access device, one placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

The client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin.

B. Increase the heparin rate. For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low - the heparin rate will need to be increased.

A nurse is caring for four patients on IV heparin therapy. Which lab value possibly indicates that a serious side effect has occurred? A. Hemoglobin 14.2 g/dL B. Platelet count 82,000/L C. RBC Count 4.8/mm3 D. WBC Count 8700/mm3

B. Platelet count 82,000/L This platelet count is low and could indicated heparin-induced thrombocytopenia. The other values are normal for either gender.

A client is hospitalized with a second episode of PE. Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? A. Instruct the client to eliminate all vitamin K from the diet. B. Prepare preoperative teaching for an inferior vena cava (IVC) filter C. Refer the client to a chronic illness support group. D. Teach the client to use a soft-bristled toothbrush.

B. Prepare preoperative teaching for an inferior vena cava (IVC) filter Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have a much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order and IVC filter device to be implanted.

A nurse caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? A. Redness at the catheter insertion site B. Report of headache and stiff neck C. Temperature of 100.1 F (37.8C) D. Pain rating of 8 on a scale of 0-10

B. Report of headache and stiff neck Complication of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101F (37.8C) are signs of meningitis and would be reported the HCP immediately. The other findings are important but not require immediate intervention.

Which information about spiritual needs would the nurse consider when planning care? A. Spiritual needs cannot be met without religion B. Spiritual needs are whatever gives purpose to a patient's life C. Spiritual needs should focus on the patient's relationship with God D. Spiritual needs should focus only on the patient's designated religion.

B. Spiritual needs are whatever gives purpose to a patient's life

Which alternative term would the nurse use when discussing spiritual distress? A. Moral B. Religious C. Existential D. Psychosocial

C. Existential

Which drug would the nurse expect the physician to prescribe for a terminally ill patient who is experiencing delirium? A. Atropine B. Lorazepam C. Haloperidol D. Furosemide

C. Haloperidol Delirium may occur in a week or two before death. Haloperidol (antipsychotic) is the drug of choice for such cases.

A nurse is assisting the primary HCP who is intubating a client. The HCP has been attempting to intubate for 40 sections. What action by the nurse is best? A. Ensure that the client has adequate sedation. B. Find another qualified provider to intubate. C. Interrupt the procedure to give oxygen. D. Monitor the client's oxygen saturation.

C. Interrupt the procedure to give oxygen. Each intubation attempt should not exceed 30 seconds (15 seconds is preferable) as it causes hypoxia. The nurse nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the patient's O2 sat but these do not take priority.

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? A. Determine if the tube is kinked. B. Ensure all connections are patent. C. Listen to the clients lung sounds. D. Suction the endotracheal tube.

C. Listen to the clients lung sounds. When an intubated client shows signs of hypoxia, check for DOPE: Displaced tube (most common cause), Obstruction (often by secretions), Pneumothorax, and Equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed.

A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate tot he assistive personnel? A. Assess the client for sedative needs B. Get family permission for restraints C. Provide frequent oral care per protocol D. Use nonverbal pain assessment tools

C. Provide frequent oral care per protocol

A client is admitted with a pulmonary embolism (PE). The client is a young, healthy, and active and has no know risk factors for PE. What action by the nurse is most appropriate? A. Encourage the client to walk 5 minutes each hour. B. Refers the client to smoking cessation classes. C. Teach the client about factor V Leiden testing D. Tell the client that sometimes no cause for disease is found

C. Teach the client about factor V Leiden testing Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk or not smoke is healthy but not related to development of PE.

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? A. Breathing so rapidly interferes with oxygenation. B. Maybe the client has respiratory distress syndrome. C. The blood clot interferes with perfusion in the lungs. D. The client needs immediate intubation and mechanical ventilation.

C. The blood clot interferes with perfusion in the lungs. A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating. ARDS can occur but this is not as likely soon after the client starts on oxygen. The client may need to be mechanically ventilated but without concrete data on FiO2 and SaO2 the nurse cannot make that judgement.

Which question would the nurse ask when beginning a spiritual assessment? A. With which religion do you identify? B. Do you have an advanced directive? C. What gives you meaning in your life? D. Are there any rituals that you want to continue?

C. What gives you meaning in your life?

Cheyne-Stokes respiration

Common sign of nearing death in which apnea alternates with periods of rapid breathing.

Which action would the nurse take for the dying patient who develops oliguria while on morphine therapy? A. Continue the morphine therapy B. Decrease the dose of morphine C. Use complementary therapy such as aromatherapy to reduce pain D. Consult with the HCP for a change in prescription

D. Consult with the HCP for a change in prescription The nurse should consult with the HCP to change the medication to fentanyl citrate. Without proper output - the patient can become delirius.

A patient with terminal pancreatic cancer who is near death reports increasing shortness of breathing with associated anxiety. Which hospice protocol prescription would the nurse implement first? A. Prednisone elixir 10 mg orally B. Albuterol 0.5% solution per nebulizer C. Oxygen 2 to 6 L/min per nasal cannula D. Morphine sulfate 5 to 10 mg sublingually as needed.

D. Morphine sulfate 5 to 10 mg sublingually as needed.

A nurse assess a client who has a radial artery catheter. Which assessment will the nurse complete first? A. Amount of pressure in fluid container. B. Date of catheter tubing change. C. Type of dressing over the site. D. Skin color and capillary refill.

D. Skin color and capillary refill. An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses are assessment for circulation distal to the catheter site.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? A. Apply cold compresses to the IV site B. Elevate the extremity on a pillow C. Flush the catheter with normal saline D. Stop the infusion of IV fluids

D. Stop the infusion of IV fluids Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client's comfort.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? A. The catheter has been in place for 20 hours B. The client has poor vascular access in the upper extremities C. The catheter is placed in the proximal tibia D. The client's left lower extremity is cool to the touch

D. The client's left lower extremity is cool to the touch Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? A. The client is able to initiate spontaneous breaths B. The inspired oxygen has adequate humidification C. The upper peak airway pressure limit alarm is off. D. The upper peak airway pressure limit if off.

D. The upper peak airway pressure limit if off. The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Initiating spontaneous breathing is important for some mode of ventilation but not others. Adequate humidification is important but does not take priority.

For which purpose would the nurse administer atropine solution sublingually to a dying patient with dyspnea? A. To treat bronchospasms B. To decrease fluid overload C. To treat respiratory infection D. To dry up respiratory secretions

D. To dry up respiratory secretions

A nurse is assessing clients who have IV therapy prescribed. Which assessment finding for a client with a PICC requires immediate attention? A. The initial site dressing is 3 days old B. The PICC was inserted 4 weeks ago C. A securement device is absent D. Upper extremity swelling is noted

D. Upper extremity swelling is noted Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site would be changed within 24 hours, but this does not take priority. The dwell time for PICCs can be months to years.

Ventilator-Associated Lung Injury/Ventilator-Induced Lung Injury (VALI/VILI)

Damage from prolonged ventilation causing loss of surfactant, increased inflammation, fluid leakage, and noncardiac pulmonary edema).

Extravasation

Escape of fluids or drugs into the subcutaneous tissue; a complication of intravenous infusion therapy.

Catheter-Related Bloodstream Infection (CRBSI)

Health care−acquired bloodstream infections caused by the presence of any type of intravenous catheter.

Refractory Hypoxemia

Hypoxemia that persists even when 100% oxygen is given.

Phlebitis

Inflammation of a vein that can predispose patients to thrombosis.

Biotrauma

Inflammatory response-mediated damage to alveoli

Ambulatory Pumps

Infusion therapy pump generally used with a home care patient to allow a return to his or her usual activities while receiving infusion therapy.

What are risk factors for VTE leading to PE?

Major risk factors for VTE leading to PE are: • Prolonged immobility • Central venous catheters • Surgery • Pregnancy • Obesity • Advancing age • General and genetic conditions that increase blood clotting • History of thromboembolism • Smoking • Estrogen Therapy

DNR (do not resuscitate)

Order from physician or other authorized primary health care provider, which instructs that CPR not be attempted in the event of cardiac or respiratory arrest.

advanced care planning

Process of patients thinking about and communicating their preferences about end-of-life care

euthanasia

Term used to describe the process of ending life. Active euthanasia implies that primary health care providers take action (e.g., give medication or treatment) that purposefully and directly causes the patient's death.

Reminiscence

The process of randomly reflecting on memories of events in one's life.

flail chest

The result of fractures of at least two neighboring ribs in two or more places causing paradoxical chest wall movement (inward movement of the thorax during inspiration, with outward movement during expiration).

Volutrauma

Ventilator-induced damage to the lung by excess volume delivered to one lung over the other.

Barotrauma

Ventilator-induced damage to the lungs from positive pressure.

Atelectrauma

Ventilator-induced trauma of shear injury to alveoli from opening and closing

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? A. Assess the clients lung sounds. B. Notify the Rapid Response Team. C. Provide reassurance to the client. D. Take a full set of vital signs.

b. Notify the Rapid Response Team. The client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify RRT for speedy diagnosis and treatment. The other actions are appropriate but are not the priority.