Med Surg Test #1 Powerpoint Practice Questions

A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? "The pain is controlled, so there is no damage." "It will take years to know the extent of the damage to the heart muscle." "The medication will dilate the blood vessels and any damage will be corrected." "A heart attack evolves over several hours. We won't know the extent of the damage immediately."

"A heart attack evolves over several hours. We won't know the extent of the damage immediately." Infarction is a dynamic process that does not occur instantly. The MI evolves over a period of several hours. Controlled pain does not indicate that there is no cardiac muscle damage. The medications do vasodilate to prevent further damage. They do not correct damage that has already been incurred.

Three days later, the provider prepares to discharge the patient on warfarin (Coumadin). Which teaching points do you include about this therapy? (Select all that apply.) "Be sure to have follow-up INR laboratory tests done." "Report any bruising or bleeding to your provider." "Consume lots of foods that are rich in vitamin K, such as green leafy vegetables." "Use a soft toothbrush to brush your teeth and an electric razor to shave your legs." "A skin rash is expected while you are taking this drug."

"Be sure to have follow-up INR laboratory tests done." "Report any bruising or bleeding to your provider." "Use a soft toothbrush to brush your teeth and an electric razor to shave your legs." It will be important for the patient to have follow-up INR laboratory tests done, reporting any bruising or bleeding, and use a soft toothbrush and electric razor while on warfarin therapy. Vitamin K is the antidote for warfarin, so patients should not consume a great deal of foods that are high in this vitamin. A skin rash is a sign of an adverse drug reaction and should be reported to the provider immediately.

At the end of the visit, the provider prescribes hydrochlorothiazide (HydroDIURIL) 25 mg PO each morning to manage the patient's hypertension. Which statement do you include when teaching the patient about this drug? "This is a loop diuretic that decreases sodium reabsorption." "Eat foods rich in potassium, such as bananas and orange juice." "A potassium supplement will be prescribed along with this drug." "HydroDIURIL is a potassium-sparing diuretic that helps prevent the loss of essential potassium."

"Eat foods rich in potassium, such as bananas and orange juice." Hydrochlorothiazide is a thiazide diuretic. The most frequent side effect is hypokalemia, so it's important to teach patients the signs of low potassium, as well as which foods are rich in potassium. Some patients need a potassium supplement, but this is prescribed based on the patient's serum potassium level.

A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? "I should limit my alcohol consumption." "I should eat more green leafy vegetables like spinach." "I should take the medication at the same time every day." "I should make a doctor's appointment for weekly blood draws."

"I should eat more green leafy vegetables like spinach." Patients who experience a venothromboembolism/pulmonary embolism are frequently discharged on anticoagulant therapy (e.g., warfarin [Coumadin]). The patient should be educated to understand the risks and monitoring of this drug to include weekly monitoring for therapeutic levels, consistency in dosing regimens, and foods to avoid (e.g., leafy green vegetables, green tea, alcohol, cranberry juice).

A patient was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night. The nurse immediately checks on the patient and finds that she appears anxious and her vital signs are as follows: Blood pressure: 128/84 mm Hg Heart rate: 114 (sinus tachycardia) Respiratory rate: 24 and labored Temperature: 99.4º F (axillary) O2 saturation: 91% on 40% O2 via trach collar Which of these findings are cause for concern?

-Respiratory rate: 24 and labored -O2 saturation: 91% on 40% O2 via trach collar Airway is always priority.

Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? 24-year-old male admitted with blunt chest trauma and aspiration 56-year-old male with a history of alcohol abuse and chronic pancreatitis 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells 82-year-old female on antibiotics for pneumonia

24-year-old male admitted with blunt chest trauma and aspiration All patient scenarios create a risk for ARDS. However, the trauma patient with direct chest injury and known aspiration is at greatest risk. ARDS risk factors include direct lung injury (most commonly aspiration of gastric contents), systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors include bacteremia, trauma with or without pulmonary contusion, multiple fractures, burns, massive transfusion, near drowning, post-perfusion injury after cardiopulmonary bypass surgery, pancreatitis, and fat embolism.

The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.) A. Weight loss B. Nasal mask to deliver BiPAP C. A change in sleeping position D. Medication to increase daytime sleepiness E. Position-fixing device that prevents tongue subluxation

A, B, C, E Rationale: All interventions listed are viable interventions that can be of benefit to patients who have sleep apnea. Patients should work with their providers of care to determine the severity of their sleep apnea and which specific interventions would be of most importance to them. Encouraging daytime sleepiness is the opposite of the effect needed for this patient.

The provider discusses radiation therapy with the patient because her lesion is small and the cure rate is 80% or higher. The patient asks if her voice will return to normal. What is the appropriate nursing response? (Select all that apply.) A. "At first the hoarseness may become worse." B. "The more you use your voice, the quicker it will improve." C. "Gargling with saline may help decrease the discomfort in your throat." D. "Your voice will improve within 4 to 6 weeks after completion of the therapy." E. "You should rest your voice and use alternative communication during the therapy."

A, C, D, and E The patient should be taught not to use her voice more than necessary during and after therapy, and to work with family to determine alternative forms of communication until after the radiation therapy. Statements A, C, D, and E are appropriate responses that accurately reflect the normal course of progression after radiation therapy for throat cancer. -gargling with saline (salt water) what does it help? Reduces the swelling and bacteria. If there's bleeding it will shrink the cells a little bit. Gets rid of any smell, can reduce infection. Can prevent super infection from occurring. -will improve week by week, but it is individual but it will improve and get better over time.

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Administer the rescue drugs. B. Take the patient's vital signs. C. Notify the patient's prescriber. D. Repeat the PEF reading to verify the results.

A. Administer the rescue drugs. A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive rescue drugs immediately, and then the prescriber should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs.

The nurse understands which symptom to be a hallmark subjective sign of lung disease? A. Cough B. Dyspnea C. Chest pain D. Sputum production

A. Cough Rationale: Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.

A patient was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night. After morning care, the student nurse is to perform tracheostomy care under the RN's supervision. Which instructions does the RN give the student nurse? (Select all that apply.) A. Create a sterile field. B. Change trach ties if soiled. C. Remove old dressings and excess secretions. D. Suction the tracheostomy tube after the trach care. E. Clean the inner cannula with full-strength hydrogen peroxide.

A. Create a sterile field. B. Change trach ties if soiled. C. Remove old dressings and excess secretions. The student nurse should be taught to suction the tracheostomy tube BEFORE performing trach care if needed. The inner cannula should be cleaned with half-strength hydrogen peroxide, followed by sterile saline, and dried to prevent any of the solution from entering the tracheostomy.

A 58-year-old woman who has been diagnosed with throat cancer 1 week ago comes to the clinic today to discuss surgical options with her health care provider. She is very tearful and appears sad when the nurse calls her back to the examination room. Based on her diagnosis, which clinical manifestation will the nurse likely observe in the patient? A. Hoarseness B. Severe chest pain C. Low hemoglobin level (anemia) D. Numbness and tingling of the face

A. Hoarseness The patient may experience several different symptoms. The most commonly seen with throat cancer is hoarseness, as well as mouth sores or a lump in the neck. Anemia can result if surgery is performed. Severe pain in the chest can be associated with many different disorders and is not usually linked to throat cancer. Numbness and tingling of the face cannot be observed. Don't read more into it. What is the most likely thing you are to observe.

On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? Synchronized cardioversion CPR and immediate defibrillation Administration of IV amiodarone (Cordarone) and dextrose Administration of oxygen and observation of the heart rhythm

Administration of oxygen and observation of the heart rhythm Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the RED zone. What is the priority nursing action? A. Administer the rescue drugs. B. Take the patient's vital signs. C. Notify the patient's prescriber. D. Repeat the PEF reading to verify the results.

Answer: A Rationale: A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive rescue drugs immediately, and then the prescriber should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs.

While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The provider writes several orders. Which order is most important for the nurse to implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 min after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP

Answer: B All of the provider's orders are very important, but based on the patient's severe shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU as soon as possible. Once the patient arrives in the ICU, they can administer the one-time dose of Solu-Medrol.

True or False: Flammable solutions containing high concentrations of alcohol or oil should not be used in rooms with oxygen. Therefore, hand hygiene using alcohol-based foams or gels should be avoided when caring for patients on oxygen therapy. A. True B. False

B (False) Rationale: Flammable solutions containing high concentrations of alcohol or oil are not used in rooms in which oxygen is in use. However this does not include alcohol-based hand rubs.

The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath when resting during the assessment. The provider plans to discharge the patient on home oxygen in the morning. What should the nurse include in this patient's discharge teaching?

Answer: Make sure that the patient understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.

The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias? Atrial fibrillation Sinus tachycardia Sinus bradycardia Ventricular fibrillation

Atrial fibrillation Atrial fibrillation (AF) is the most common dysrhythmia seen in clinical practice. It is responsible for a third of hospitalizations for cardiac rhythm disturbances. Patients can live with this dysrhythmia, but most are treated with anticoagulation therapy to avoid possible blood clots.

A patient is admitted with cough, fever, sore throat, progressive shortness of breath, diarrhea, and vomiting that developed after returning from a business trip overseas. The nurse suspects which illness is the likely cause of the patient's symptoms? Pneumonia Viral influenza Avian influenza Tuberculosis exposure

Avian influenza The initial manifestations of avian influenza are similar to other respiratory infections but include cough, fever, sore throat, shortness of breath, pneumonia, diarrhea, vomiting, abdominal pain, and bleeding from the nose and gums. Assess whether the patient has recently (within the past 10 days) traveled to areas of the world affected by H5N1. Pneumonia and tuberculosis exposure will not present with gastrointestinal symptoms.

55-year-old woman with a long history of COPD and 40 years of smoking cigarettes is being admitted to the pulmonary stepdown unit from the ED. The ED nurse reports that the patient is on oxygen at 2 L per nasal cannula after having bronchodilator respiratory treatment in the ED. She has bilateral expiratory wheezes and crackles both anteriorly and posteriorly. A saline lock was placed in her right forearm for intermittent medications. Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance

B, C, D, E B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.

The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)? A. 29-year old male who is overweight B. 32-year-old female with a family history of PH C. 43-year-old male with history of right-sided heart failure D. 50-year-old female with history of blood clots in the pulmonary artery

B. 32-year-old female with a family history of PH Family history is a primary risk assessment variable related to pulmonary hypertension (PH) and pulmonary artery hypertension (PAH). The disease usually develops between the ages of 20 to 60, and occurs more often in women. Other risk factors include obesity, heart and lung diseases, HIV infection, and history of pulmonary embolisms

The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)? A. 29-year old male who is overweight B. 32-year-old female with a family history of PH C. 43-year-old male with history of right-sided heart failure D. 50-year-old female with history of blood clots in the pulmonary artery

B. 32-year-old female with a family history of PH Rationale: Family history is a primary risk assessment variable related to pulmonary hypertension (PH) and pulmonary artery hypertension (PAH). The disease usually develops between the ages of 20 to 60, and occurs more often in women. Other risk factors include obesity, heart and lung diseases, HIV infection, and history of pulmonary embolisms.

The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? A. 25% B. 50% C. 75% D. 100%

B. 50% Rationale: Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with oxygen.

The nurse understands which is the primary risk factor for lung cancer? A. Air pollution B. Cigarette smoking C. Chronic exposure to asbestos D. Occupational radiation exposure

B. Cigarette Smoke (Not cigarette smoking according to Carole in class, she said Air Pollution) According to the American Cancer Society, cigarette smoking remains the primary risk factor and is responsible for 9 out of 10 cases of lung cancer. Occupational exposure, secondhand smoke, asbestos, advancing age, and family history are additional risk factors.

A patient was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night. Based on the patient's vital signs, what is the appropriate nursing action? A. Inform the provider of abnormal vital signs. B. Complete an assessment of airway and respiratory status. C. Provide patient teaching regarding relaxation techniques. D. Notify the Rapid Response Team for extra assistance.

B. Complete an assessment of airway and respiratory status. The patient may be experiencing some problems with her respiratory system. She had problems maintaining her saturation during the night, and her low oxygen saturation has not improved. Therefore, the nurse should complete an assessment to be able to report any abnormal findings to the health care provider. The nurse should not call the provider before doing this. The patient's anxiety may be related to the lack of oxygen. Patient teaching regarding relaxation techniques, once an assessment of the airway demonstrates patency, can be helpful in reducing symptoms associated with anxiety. Once this problem is resolved, her heart rate and respiratory rate are expected to return to normal. The Rapid Response Team should be notified only if the patient has a further decline in respiratory status.

While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The provider writes several orders. Which order is most important for the nurse to implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 min after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP

B. Increase O2 to 3 L per nasal cannula All of the provider's orders are very important, but based on the patient's severe shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU as soon as possible. Once the patient arrives in the ICU, they can administer the one-time dose of Solu-Medrol.

The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? A. Fever B. Cough C. Confusion D. Weakness

C. Confusion The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.

After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hr for temp above 101º F Cefazolin (Ancef) 1 g IVP every 8 hr Which of the provider's orders should the nurse implement first? A. IV fluids 1000 mL .9 NS at 60 mL/hr B. Oxygen at 2 L per nasal cannula C. Blood cultures and urinalysis D. Cefazolin (Ancef) 1 g IVP every 8 hr

B. Oxygen at 2 L per nasal cannula All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.

An 83-year-old patient is brought to the ED reporting a productive cough with fever for the last 48 hours. She appears flushed and very short of breath when answering questions. She has a history of type 2 diabetes mellitus and hypertension, but no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) are drawn in the ED. A saline lock is inserted into her right forearm. She is admitted to the medical-surgical unit with a diagnosis of suspected pneumonia. The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG - 239 mg/dL BP - 138/88 mm Hg HR - 128 RR - 36 breaths/min O2 saturation - 88% (room air) Temp - 101.6º F Which vital sign or test result requires the nurse's immediate attention? A. Blood pressure B. Respiratory rate C. Temperature D. Blood glucose

B. Respiratory rate All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.

A 55-year-old woman with a long history of COPD and 40 years of smoking cigarettes is being admitted to the pulmonary stepdown unit from the ED. The ED nurse reports that the patient is on oxygen at 2 L per nasal cannula after having bronchodilator respiratory treatment in the ED. She has bilateral expiratory wheezes and crackles both anteriorly and posteriorly. A saline lock was placed in her right forearm for intermittent medications. Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance

B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.

The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication? A. Pneumothorax B. Tracheomalacia C. Subcutaneous emphysema D. Trachea-innominate artery fistula

B. Tracheomalacia Rationale: Tracheomalacia can develop because of the constant pressure exerted by the cuff, causing tracheal dilation and erosion of cartilage. Pneumothorax can develop during any tracheostomy procedure if the thoracic cavity is accidentally entered. Subcutaneous emphysema can develop during any tracheostomy procedure if air escapes into fresh tissue planes of the neck. Trachea-innominate artery fistula can occur any time a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.

A patient with cardiovascular disease is prescribed a potassium-wasting diuretic. The nurse will recommend that the patient consume which food to help prevent hypokalemia? Dried figs Red apples Raw avocados Baked potatoes

Baked potatoes Many fruits, beans, and vegetables are high in potassium; however, a baked potato has approximately 1000 mg of potassium, an avocado has 180 mg, dried figs have 271 mg, and an apple has 160 mg. The patient should be encouraged to read nutrition labels for nutrient information as well.

After assessing the patient, you document the following: Jugular venous distention 2+ edema in feet and ankles Swollen hands and fingers Distended abdomen Bibasilar crackles on auscultation Productive cough with pink-tinged sputum What is your most likely interpretation of these findings? Biventricular failure Class IV heart failure Left-sided heart failure Right-sided heart failure

Biventricular failure The patient has key features of both right-sided and left-sided heart failure.

A patient is admitted with cough, fever, sore throat, progressive shortness of breath, diarrhea, and vomiting that developed after returning from a business trip overseas. The nurse suspects which illness is the likely cause of the patient's symptoms? A. Pneumonia B. Viral influenza C. Avian influenza D. Tuberculosis exposure

C. Avian influenza Rationale: The initial manifestations of avian influenza are similar to other respiratory infections but include cough, fever, sore throat, shortness of breath, pneumonia, diarrhea, vomiting, abdominal pain, and bleeding from the nose and gums. Assess whether the patient has recently (within the past 10 days) traveled to areas of the world affected by H5N1. Pneumonia and tuberculosis exposure will not present with gastrointestinal symptoms.

The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform? A. Encourage hydration with water. B. Feed the patient if coughing occurs. C. Encourage the patient to sit in a chair for meals. D. Encourage the patient to drink juice to address thirst.

C. Encourage the patient to sit in a chair for meals. Rationale: Several interventions are necessary to reduce the risk of aspiration. Having the patient sit upright to eat is an important initial step to reduce aspiration. Other interventions include encouraging liquids that are "thick." Avoiding thin liquids like juice, water, and fruits that produce juice are important strategies to reduce aspiration risks. Coughing may be a sign of difficulty with swallowing or aspiration and requires additional assessment.

While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action? A. Instruct the patient to cough. B. Place the patient in a high Fowler's position. C. Oxygenate the patient with 100% oxygen. D. Instruct the patient to breathe slowly and deeply.

C. Oxygenate the patient with 100% oxygen. Rationale: Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation.

The nurse is preparing to admit an adult patient with pertussis. Which symptoms does the nurse anticipate finding in the EMR? a. Hemostasis b. Mild cold like symptoms C. Post cough Emesis d. "Whooping" after a cough

C. Post Cough Emesis

The nurse understands which is the primary risk factor for lung cancer? A. Air pollution B. Cigarette smoking C. Chronic exposure to asbestos D. Occupational radiation exposure

Cigarette Smoking Rationale: According to the American Cancer Society, cigarette smoking remains the primary risk factor and is responsible for 9 out of 10 cases of lung cancer. Occupational exposure, secondhand smoke, asbestos, advancing age, and family history are additional risk factors. (per Carole the answer is A, but her rational under the slide says cigarette smoking)

The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? Fever Cough Confusion Weakness

Confusion The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.

Fifteen minutes after the oxygen is replaced via nasal cannula and he has rested, the patient denies being short of breath. You obtain an oxygen saturation, which is 96%. Based on this result, what should you do next? Call the provider as soon as possible. Encourage the patient to take some deep breaths. Increase the oxygen level to 5 L per nasal cannula. Continue the assessment, as 96% is considered acceptable.

Continue the assessment, as 96% is considered acceptable. Once the patient's oxygen is replaced, he denies shortness of breath. The supplemental oxygen and a period of rest resulted in his oxygen saturation being 96%, which is acceptable. The oxygen should not be increased, nor does he need to take deep breaths because the patient's SaO2 is normal and he is not short of breath.

When the nurse begins taking the patient's history, the patient asks, "Did you know that I have throat cancer and may not survive?" What is the appropriate nursing response? A. "Are you having difficulty swallowing?" B. "My mother had cancer, so I know how you must be feeling right now." C. "I am sure that your cancer can be cured if you follow your doctor's advice." D. "I know you have been diagnosed with cancer. Are you concerned about what the future may hold?"

D. "I know you have been diagnosed with cancer. Are you concerned about what the future may hold?" Although answer A is part of an appropriate history, the patient's need at the moment, represented by her statement, is psychosocial in nature. The nurse should realize that the patient may need psychosocial support. This is the only appropriate therapeutic response. The nurse cannot give her false reassurance (answer C), and the nurse should never compare feelings (answer B). Head and neck cancer is curable when treated early.

The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding is most serious? A. Malaligned nasal bridge B. Blood draining from one of the nares C. Crackling of the skin (crepitus) upon palpation D. Clear glucose positive fluid draining from nares

D. Clear glucose positive fluid draining from nares Rationale: Blood or clear fluid (cerebrospinal fluid, or CSF) may drain from one or both nares. However, the presence of glucose in the clear drainage indicates that CSF is draining, which could be caused by a skull fracture, a serious complication. A malaligned nasal bridge and crepitus may be observed when evaluating general facial fractures.

The nurse understands that the expected assessment for the older adult related to the natural aging process of the respiratory system includes which finding? A. Tightening of the vocal cords B.Decrease in residual volume C. Decrease in the anteroposterior diameter D. Decrease in respiratory muscle strength

D. Decrease in respiratory muscle strength Rationale: As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases.

A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? A. Influenza B. Pneumonia C. Tuberculosis D. Pulmonary empyema

D. Pulmonary empyema Patients with pneumonia, tuberculosis, and influenza may experience some or all of the symptoms of fever, chills, night sweats, and weight loss. However, because pulmonary empyema is a collection of pus in the pleural space that may cause compromised cardiac function, displaced point of maximal impulse (PMI), and hypotension may result.

A patient was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night. As the assessment is completed, the nurse observes that the patient has a large amount of thick secretions visible in the trach. What is the priority nursing action? A. Add pulmonary toileting to daily interventions. B. Instruct the UAP to sit with the patient until she is calmer. C. Call the respiratory therapist for a stat bronchodilator treatment. D. Suction the artificial airway and remove the secretions.

D. Suction the artificial airway and remove the secretions. The most important intervention is to clear the airway. It is not necessary to call the respiratory therapist at this time. The secretions are tenacious and copious, which indicates a potential problem. Once her airway is clear, then all of the other options can be considered. The patient should be monitored very carefully and the health care provider notified about these findings.

The older patient with coronary artery disease (CAD) is more likely to have what symptom if experiencing cardiac ischemia? Syncope Dyspnea Chest pain Depression

Dyspnea Chest pain may not be evident in the older patient with CAD. Associated symptoms such as unexplained dyspnea, confusion, or GI symptoms may be noted.

In 2013, the ACA/AHA developed guidelines to reduce cardiovascular risk and decrease blood pressure. Which interventions relate to these guidelines? (Select all that apply.) Use only sugar in beverages. Engage in aerobic exercise 3 to 4 times per week. Develop a dietary plan that includes fish, legumes, and nuts. Include at least 3000 mg of sodium per day in the dietary plan. Encourage a dietary pattern of vegetables, fruits, and whole grains.

Engage in aerobic exercise 3 to 4 times per week. Develop a dietary plan that includes fish, legumes, and nuts. Encourage a dietary pattern of vegetables, fruits, and whole grains.

After the radiation therapy begins, the patient visits the clinic stating that her throat is sore, she is having difficulty swallowing, and the skin on her throat is red, tender, and peeling. What patient teaching should the nurse provide?

For temporary relief of the patient's sore throat and swallowing difficulty, suggest that she gargle with saline, suck on ice chips, use mouthwash, or use a throat spray with local anesthetics such as lidocaine. For her red, tender, peeling skin, have her avoid exposure to sun, heat, cold, or abrasive treatments such as shaving; wear protective clothing of soft cotton; wash gently with mild soap; and use only lotions or powders prescribed by the radiation oncologist until the area has healed.

Which cardiovascular disease results in the highest number of hospital admissions in the United States? Heart failure Rheumatic carditis Mitral valve disease Infective endocarditis

Heart failure According to the American Heart Association, heart failure affects nearly 5.7 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined. It is the number one cause for hospitalizations among Medicare patients. With improvement in survival of acute MIs and a population that continues to age, heart failure will continue to increase in prominence as a major health problem in the United States

What is the most common symptom associated with hypertension? Headache Slurred speech Fainting and dizziness Hypertension is often asymptomatic

Hypertension is often asymptomatic Hypertension is often asymptomatic and has become known as the "silent killer" due to the lack of symptoms. Headaches may occur but not always. Hypertension does not cause slurred speech or fainting.

The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? Improved urinary output Improved activity tolerance Increased myocardial contractility Increased myocardial oxygen

Improved activity tolerance Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea

During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%. Based on this finding, which medications might the provider order? (Select all that apply.) Multivitamin 1 PO each day Lisinopril (Zestril) 5 mg PO daily Digoxin (Lanoxin) 0.25 mg PO daily Ibuprofen (Advil) 200 PO mg twice daily Furosemide (Lasix) 20

Lisinopril (Zestril) 5 mg PO daily Digoxin (Lanoxin) 0.25 mg PO daily Furosemide (Lasix) 20 Commonly prescribed drug classes for patients with heart failure include ACE inhibitors (lisinopril), diuretics (furosemide), nitrates (digoxin), human B-type natriuretic peptides, inotropics, and beta-adrenergic blockers.

The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath when resting during the assessment. The provider plans to discharge the patient on home oxygen in the morning. What should the nurse include in this patient's discharge teaching?

Make sure that the patient understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.

Identify appropriate interventions for a patient experiencing inadequate oxygenation and tissue perfusion as a result of coronary artery disease. (Select all that apply.) Notify the physician. Administer Tylenol for pain. Maintain or initiate an IV line. Apply oxygen via nasal cannula. Encourage interaction with family. Administer nitroglycerin sublingually.

Notify the physician. Maintain or initiate an IV line. Apply oxygen via nasal cannula. Administer nitroglycerin sublingually. Refer to Chart 38-3 in the textbook (p. 764) for the complete rationale

When the ED physician is notified of the patient's manifestations, and she is moved immediately to a treatment room. The physician writes the following orders: O2 at 2 L per nasal cannula Stat CBC, BMP, d-dimer, aPTT, INR Stat CT of the chest Start a saline lock Which order takes priority at this time?

O2 at 2 L per nasal cannula Based on the patient's pulse oximetry reading, the priority order is the administration of oxygen. Next, the saline lock should be started. Once the vein is accessed, blood can also be obtained for the CBC, BMP, d-dimer, PTT, and INR. After the laboratory specimens are sent, the radiology department can be notified to perform the stat CT of the chest.

A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure? Pulmonary edema Hypovolemic shock Pulmonary embolus Opioid analgesic overdose

Opioid analgesic overdose Acute ventilatory failure is the type of problem in oxygen intake and carbon dioxide removal (ventilation) and blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. It occurs when chest pressure does not change enough to permit air movement into and out of the lungs. As a result, too little oxygen reaches the alveoli and carbon dioxide is retained. Opioid analgesic overdose is a possible cause of ventilatory failure. The other choices listed are related to oxygenation failure.

After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hr for temp above 101º F Cefazolin (Ancef) 1 g IVP every 8 hr Which of the provider's orders should the nurse implement first? IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures and urinalysis Cefazolin (Ancef) 1 g IVP every 8 hr

Oxygen at 2 L per nasal cannula All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.

A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? Influenza Pneumonia Tuberculosis Pulmonary empyema

Patients with pneumonia, tuberculosis, and influenza may experience some or all of the symptoms of fever, chills, night sweats, and weight loss. However, because pulmonary empyema is a collection of pus in the pleural space that may cause compromised cardiac function, displaced point of maximal impulse (PMI), and hypotension may result.

Two hours later, the patient has a weak cough, crackles in both lower lobes, and an SaO2 reading of 90% by pulse oximetry. What interventions should be implemented by the nurse at this time?

The patient has developed problems with her airway. Interventions should include helping her to cough and deep breathe at least every 2 hours; teaching incentive spirometry every hour while awake; encouraging the patient to consume 3 L of fluid per day; monitoring intake and output; and administering bronchodilators if ordered.

While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP). What is the best approach for the nursing assistant to take? Place the patient on a bedpan and stay with her until she is finished. Ambulate her into the hall bathroom on room air and stand outside the door until she is done. Ask the provider for an indwelling catheter because of her shortness of breath when she ambulates. Tell her to try to wait until the shortness of breath subsides.

Place the patient on a bedpan and stay with her until she is finished. The nursing assistant should place the patient on a bedpan and stay with her. She is too short of breath to ambulate to the bathroom and she should remain on the oxygen at all times. The nursing assistant should not ask the provider about an indwelling catheter because this would only increase the possibility of a urinary tract infection (UTI). The patient should never be told to try to wait, because this could also increase the risk for UTI.

A 65-year-old woman is brought to the ED by her husband with new-onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up. What risk factors are present for VTE?

Prolonged immobility; advancing age; recent surgery.

During triage, the following vital signs and assessments are noted: Temp - 99.6º F BP - 80/44 mm Hg P - 126 (sinus tachycardia) R - 28 and labored O2 saturation - 84% (room air) Crackles bilaterally Petechiae across chest and in axillae Based on these findings, what do you suspect might be happening with the patient?

The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms. She just had surgery and is bed bound! SOB always thinking PE after surgery

A 51-year-old man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5' 8" tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table. Which action should you take first? Take his vital signs. Replace the nasal cannula. Sit him up in a bedside chair. Call the Rapid Response Team.

Replace the nasal cannula. The patient has exerted himself in ambulating to and from the bathroom. He also has been without supplemental oxygen. The first action should be to replace his nasal cannula. He has a history of heart failure and will often require supplemental oxygen. Taking his vital signs can be done once his oxygen is restored. If he wants to sit up, he should be positioned in bed, not in a bedside chair. Calling the Rapid Response Team is not necessary.

An 83-year-old patient is brought to the ED reporting a productive cough with fever for the last 48 hours. She appears flushed and very short of breath when answering questions. She has a history of type 2 diabetes mellitus and hypertension, but no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) are drawn in the ED. A saline lock is inserted into her right forearm. She is admitted to the medical-surgical unit with a diagnosis of suspected pneumonia. The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG - 239 mg/dL BP - 138/88 mm Hg HR - 128 RR - 36 breaths/min O2 saturation - 88% (room air) Temp - 101.6º F Which vital sign or test result requires the nurse's immediate attention? Blood pressure Respiratory rate Temperature Blood glucose

Respiratory rate All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.

Which symptom reported by a client who has had a total hip replacement requires emergency action? a. Localized Swelling of one of the lower extremities b. Shortness of breath and Chest pain c. Positive Homan's sign d. Redness and tenderness at the IV site

Shortness of breath and Chest pain (think PE after surgery with SOB)

When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula. Based on these findings, what should the nurse do next?

The Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC.

When using a 5-electrode lead ECG monitoring system, the nurse recognizes which lead is most optimal for detecting dysrhythmias? III V1 V5 aVR

V1 Five-electrode ECG monitoring systems use four electrode leads to provide six limb lead tracings (leads I, II, III, aVR, aVL, or aVF) and the fifth electrode lead is a chest electrode that can be placed in any of the standard V1 to V6 locations. But in general, V1 is selected because of its value in detecting dysrhythmias (e.g., arrhythmia monitoring).

The nurse is assessing a patient who received a heart transplant. Which symptom suggests that the patient may be experiencing organ rejection? Fever Weight gain Tachycardia Hypertension

Weight gain Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain (edema, increased weight), abdominal bloating, new bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction (late sign).

Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol. Which finding indicates that the heparin infusion is therapeutic? INR is less than 1. INR is between 2 and 3. aPTT is the same as the control. aPTT is 1.5 to 2.5 times the control.

aPTT is 1.5 to 2.5 times the control. When a patient is started on continuous heparin, the aPTT is drawn before therapy is started and then every 4 hours until a therapeutic range of 1.5 to 2.5 times the control is reached. Thereafter, the aPTT is checked daily. (PTT more for heparin, INR for coumadin/warfarin)

Your patient exhibits no ST elevation on EKG, yet is positive for biomarkers. You assess the following: a. STEMI b. NSTEMI c. Unstable angina d. stable angina e. Chest Pain

b. NSTEMI

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? a. Pedal edema b. Urine output of 1500 mL on the preceding day c. Crackles in the lung fields d. Expectoration of yellow sputum

c. Crackles in the lung fields

Which symptom of pneumonia may present differently in the older adult than in the younger adult? a. Wheezing b. Crackles at the lung bases c. Fever d. Coughing

c. Fever

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the? a. Feet b. Hands c. Neck d. Sacrum

c. Neck

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? a. When taking Coumadin, I may notice some blood in my urine." b. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." c. "I can use an electric razor or a regular razor." d. "Eating foods like green beans won't interfere with my Coumadin therapy."

d. "Eating foods like green beans won't interfere with my Coumadin therapy."

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? a. Dietary Consult b. Sodium Restriction c. Daily Weights d. All the above

d. All the above

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? a. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase b. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol c. Homocysteine and C-reactive protein d. CK-MB and troponin

d. CK-MB and troponin

6. When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? a. Try replacing your usual breakfast with oatmeal or Cream of Wheat b. Drink more Milk and milk products c. Increase red meat in the diet d. Eat baked potatoes and melons

d. Eat baked potatoes and melons

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? a. Carotid pulses b. Femoral pulses c. Dye allergies d. Pedal pulses

d. Pedal pulses

Obstructive sleep apnea is recognized as an independent risk factor for: a.disruption in normal cardiac rhythm b.Hypertension c.Venous insufficiency d.Both a and b

d.Both a and b

Classic symptoms of TB include which of the following: a. Anorexia b. Night sweats c. Hemoptysis d. Both A and C e. All of the above

e. All of the above

Risk factors for the development of pulmonary emboli include: a. Varicose veins or venous stasis b Diabetes c. Obesity d. Both a and c e. All of the above

e. All of the above

When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula. Based on these findings, what should the nurse do next?

he Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC.