Med Surge II Ch. 31, 32

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."

A patient with a pulmonary embolism is being discharged home on warfarin. Which response suggests the patient requires additional teaching about warfarin therapy by the nurse prior to discharge?

"I can use a rectal suppository if I become constipated." Rationale: Several safety precautions important for the patient to understand about bleeding when being discharged on warfarin. The patient should take stool softeners to prevent hard stools or straining but should not insert a rectal suppository (unless they are prescribed and well-lubricated) or enema because they can cause bleeding. Avoiding contact sports, contacting the provider before going to the dentist, and using an electric shaver demonstrate appropriate knowledge about warfarin safety upon discharge.

A 75-year-old patient tells the nurse he is not planning to receive a "flu shot" this year because the shot makes him sick. What is the nurse's best response?

"The injectable flu vaccine is not a live virus and cannot cause influenza." Rationale: The influenza vaccine is not a live virus and cannot cause disease. The intranasal vaccine is a live, attenuated vaccine and is not given to people over age 49. Immunity to influenza is not conferred in subsequent years because the strains of influenza virus change each year.

The nurse has taught a patient about influenza infection control. Which patient statement indicates the need for further teaching?

"The intranasal vaccine can be given to everybody in the family." Rationale: The intranasal flu vaccine is approved for healthy patients ages 2-49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A new recommendation from the Centers for Disease Control and Prevention (CDC) for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

A young adult patient refuses an influenza vaccine, saying, "I'm healthy and won't get that sick if I get the flu." Which is the best response by the nurse?

"You may spread the disease to people who are more at risk for severe symptoms." --- In other words, a guilt trip Rationale: Young children, older adults, and those with underlying chronic conditions are at risk for pneumonia and death if they become ill with influenza. Patients who refuse the influenza vaccine should be told that they are putting others at risk. Pandemic influenzas typically originate from mutated animal and bird viruses, and prevention is handled separately from seasonal influenza—pandemic influenza vaccines are typically stockpiled and not part of general influenza vaccination. Antiviral medications are useful when given 24-48 hours after onset of symptoms, but usually shorten rather than cure the disease.

Which nursing interventions are critical in caring for individuals with influenza? Select all that apply.

1. Encouraging the patient to rest and increase fluid intake 2. Supporting the patient and preventing the spread of the disease 3. Monitoring pulse rate and quality and urine output during rehydration in a patient with diarrhea Rationale: Encouraging rest and promoting an increase in fluids is essential to promote healing. Influenza is highly contagious and emphasis should be placed on providing symptomatic support while preventing the spread of the disease to others. Assessment of pulse rate and quality and urine output will aid the health care team in monitoring the rehydration of patients who have lost significant body fluids secondary to diarrhea with the flu. Oxygen may be indicated as part of supportive care in an individual with hypoxia secondary to respiratory infections with the flu. The patient with influenza should be placed in isolation to prevent airborne spread of the disease to others.

Which nursing interventions are focused on preventing the spread of severe acute respiratory syndrome (SARS) caused by coronaviruses? Select all that apply.

1. Using strict airborne isolation techniques 2. Handwashing before and after all patient care 3. Using Contact Precautions with suspected SARS 4. Disinfecting contaminated surfaces and equipment Rationale: Since the SARS virus is spread via airborne droplets from infected people through sneezing, coughing, and talking, strict Airborne Precautions are essential. Hand hygiene and the use of gloves decrease the likelihood of spread to the mucous membranes, nose, and mouth and contamination of surfaces outside the patient's room. Individuals suspected to have SARS should be placed in Contact Precautions until a definitive diagnosis is made. Diagnosis is confirmed by the manifestation of symptoms and the use of a rapid SARS test within 2 days after symptoms begin. All equipment and surfaces that potentially have been contaminated must be disinfected by an individual wearing gloves. Although careful monitoring of the occurrence of SARS is important, preventing its spread is the initial focus to decrease the likelihood of a widespread epidemic.

What is the initial dosage of warfarin sodium used in the treatment of pulmonary embolism?

10-15 mg Rationale: The initial dosage of warfarin sodium for treating pulmonary embolism is 10-15 mg once daily for 3 days. Then, dose is adjusted based on the international normalized ratio (INR), which is usually adjusted by 5-10 mg orally daily. A dose of 15-20 mg or 20-25 mg is high for the initial administration.

Which patient has the highest risk for developing a pulmonary embolism (PE)?

25-year old woman who frequently flies to other countries Rationale: People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the patient's risk is increased. PE is a clotting disorder, not a bleeding disorder.

Of these patients waiting for an influenza immunization, which one would be eligible to receive the live attenuated vaccine (Flumist) instead of the trivalent inactivated vaccine (Fluzone)?

35-year old with allergies Rationale: The live attenuated influenza vaccine (Flumist) is recommended for healthy people up to age 49; allergies would not prevent a 35-year-old from receiving the vaccine. The 25-year-old patient should not receive the live nasal spray vaccine due to the cystic fibrosis diagnosis. The 65- and 75-year-old patients are above the age limit for administration, regardless of their health issues.

Which risk factors increase a patient's risk for venous thromboembolism that may progress to a pulmonary embolism? Select all that apply.

72 yrs old 290 lbs Presence of a central venous catheter (CVC) Rationale: Several factors place a patient at increased for developing a venous thromboembolism that may progress to a pulmonary embolism. Risk factors that should be assessed include prolonged immobility, central venous catheter, surgery, obesity, advanced age, history of thromboembolism, smoking history, pregnancy, estrogen therapy, heart failure, stroke, and cancer.

The nurse is caring for a group of patients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)?

A patient returning from an open reduction and internal fixation of the tibia Rationale: Surgery and immobility are risks for deep vein thrombosis (DVT) and PE. No evidence suggests that the patient with diabetes has been immobile, which is a risk factor for PE; the patient will be treated with antibiotics. For the patient with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the patient with hypokalemia, no evidence reveals risk for PE; no immobility or hypercoagulability is present.

A patient receiving 100% oxygen after developing pneumonitis after inhaling an irritant has worsening hypoxemia confirmed with arterial blood gases and has increasing dyspnea and work of breathing. A chest x-ray reveals a ground-glass appearance in both lungs. Which condition does the nurse suspect this patient has developed?

ARDS

Which is a serious complication of pharyngitis caused by group A streptococcal bacteria?

Acute glomerulonephritis Rationale: Acute glomerulonephritis is a serious complication of a streptococcal group A infection, which may occur 7-10 days after the infection. Pulmonary empyema is a collection of pus in the pleural space caused by pneumonia or an infected effusion. Meningitis is an infection of the meninges of the brain and can be caused by bacteria, but is not a result of having had a group A streptococcal infection. Laryngitis can be a common result of an upper respiratory infection, but is not considered a serious complication of group A streptococcus.

A patient is admitted with symptoms of periorbital and facial edema, swelling of the hands and feet, bilateral crackles in the lungs, and reddish-brown urine. The patient reports having had a fever and sore throat 10 days prior to developing symptoms. The nurse suspects that this patient may have which condition?

Acute glomerulonephritis Rationale: One complication of streptococcal pharyngitis is acute glomerulonephritis, which manifests about 7-10 days after the throat infection and is characterized by edema, fluid overload, and hematuria. Patients with streptococcal pharyngitis who do not improve with antibiotic therapy may have HIV and should be tested. A peritonsillar abscess is characterized by pain, swelling, and fever of the affected tonsil. Rheumatic fever is characterized by tremors, rash, and cardiovascular symptoms.

A newly admitted patient with respiratory distress has a chest x-ray that shows a ground-glass appearance in both lungs. The nurse notifies the provider and anticipates orders to treat which condition?

Acute respiratory distress syndrome (ARDS) Rationale: Patients who have acute respiratory distress syndrome (ARDS) have dense pulmonary infiltrates on x-ray that resemble ground glass. The chest x-ray of a patient with pulmonary embolism may have some infiltration around the embolism site or may not have any changes. A tension pneumothorax will show collapse of the affected lung. Ventilatory failure will show changes associated with the underlying cause, generally due to collapse of the alveoli.

A patient who has a venous thromboembolism in the upper arm is to be started on oral warfarin while still receiving an intravenous heparin infusion. What is the nurse's best action?

Administer meds as prescribed Rationale: Although both heparin and warfarin are anticoagulants, they have different mechanisms and onsets of action. Because warfarin has a slow onset, it must be started while the patient is still receiving heparin in order to maintain a safe level of anticoagulation for effective treatment of the venous thromboembolism. It is not necessary to clarify the order because the patient must take warfarin while on the heparin because the warfarin is slow-onset. Warfarin should not be held to wait for PTT because PTT is used to measure effectiveness of heparin, not warfarin. Although the nurse may implement use of a bed alarm, it is not a priority.

A patient who has pneumonia reports having chest pain associated with inspiration. The nurse notifies the provider and anticipates implementing which order?

Administering analgesic medications to alleviate discomfort Rationale: Pleuritic chest pain occurs with inspiration and is a common clinical manifestation in patients with pneumonia; analgesic medications are given to alleviate discomfort. This pain is caused by inflammation of the parietal pleura, not by an increase in infection, so another antibiotic is not indicated. Because the pain is associated with inspiration, it is not due to myocardial infarction, so cardiac enzyme testing is not indicated. Supplemental oxygen is used for hypoxemia.

An older patient is diagnosed with pneumonia. To assist with comfort during the admission interview, what does the nurse do?

Allow the patient to rest at frequent intervals Rationale: Patients with pneumonia often have pain, fatigue, and dyspnea, which can cause anxiety. The nurse should allow frequent rest periods and should pace the interview and assessment according to the patient's fatigue level. The patient should be allowed to choose whether to get into bed or remain up in a chair.

What is the drug of choice for a patient suffering from massive pulmonary embolism who has shock symptoms?

Altepase Rationale: Fibrinolytic agents, such as alteplase, are used in the treatment of pulmonary embolism, specifically when the patient has shock and hemodynamic collapse. Enoxaparin is a low molecular weight heparin and is prescribed for a submassive pulmonary embolism. Rivaroxaban is an anticoagulant that prevents deep vein thrombosis and pulmonary embolism and it is prescribed when the patient is at low risk for pulmonary embolism. Fondaparinux is a synthetic pentasaccharide factor Xa inhibitor, which is used unless the pulmonary embolism is massive or occurs with hemodynamic instability.

The nurse notifies the Rapid Response Team for a patient who develops distended neck veins, severe dyspnea, cyanosis, and syncope. The patient is hypoxic and hypotensive and has an abnormal electrocardiogram. Which medication does the nurse anticipate will be ordered immediately?

Altepase Rationale: This patient is displaying symptoms of a pulmonary embolism (PE). Patients who are hemodynamically unstable will need a fibrinolytic drug to break up the clot causing the PE. Heparin is used when the patient is stable to prevent the clot from getting larger. Clopidogrel is used to prevent PE in nonhospitalized patients. Coumadin is used after the patient is stable, as it generally takes 72 hours to produce anticoagulation.

Which antidote is used for blocking fibrinolytic therapy?

Aminocaproic acid Rationale: Fibrinolytic therapy is used to break up an existing clot, but these agents may cause excessive bleeding; it may be necessary to block the activity of fibrinolytic agents by using its antidote to prevent further excessive bleeding. Aminocaproic acid is the antidote for fibrinolytic therapy. Alteplase is a fibrinolytic drug that increases the risk of bleeding. Vitamin K1 is an antidote for warfarin, an oral anticoagulant used for the long-term prevention of venous thrombi. Protamine sulfate is used to block the activity of heparin.

A patient receiving intravenous alteplase (tPA) after developing a pulmonary embolism develops bloody stools and bleeding gums. The nurse notifies the provider and obtains an order for which antidote?

Aminocaproic acid Rationale: The antidote for excessive bleeding for patients receiving alteplase is aminocaproic acid. Packed red blood cells may be given if blood loss is excessive to treat anemia, but they are not used as an antidote. Phytonadione is the antidote for warfarin. Protamine sulfate is the antidote for heparin.

The community health nurse is planning tuberculosis treatment for a patient who is homeless and heroin-addicted. Which action will be most effective in ensuring that the patient completes treatment?

Arrange for a health care worker to watch the patient take the medication Rationale: Because this patient is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy (DOT). Giving a patient who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the patient to follow through. Also, the question does not indicate whether the patient can read. Simply because the patient can state the names and side effects of medications does not mean that the patient understands what the medications are and why he or she needs to take them. A patient who is homeless may be more concerned with obtaining shelter and food than with properly taking his or her medication.

The nurse is extubating a patient who has been receiving mechanical ventilation for several days. Which action is correct immediately after removal of the endotracheal (ET) tube?

Asking the patient to cough Rationale: The patient should be asked to cough immediately after removal of the ET tube to help clear secretions. The nurse should hyperoxygenate the patient and suction the oropharynx prior to removal of the ET tube. After the ET tube is safely removed, the nurse should monitor vital signs every 5 minutes initially.

An older patient with pneumonia has become more confused (decreased LOC) during the initial assessment. What action will the nurse take initially?

Assess their O2 saturation Rationale: In older patients, a frequent first indication of pneumonia is a change in mental status due to hypoxemia. The nurse should first perform a respiratory assessment and then notify the provider of the findings. Antibiotics are not indicated unless an assessment and tests indicate an infection is present. Lab work may be ordered by the provider as part of the ongoing evaluation of this patient. Nurses should listen to family members' reports about the usual status of patients and respond if a patient is not acting normally. Patients who have altered level of consciousness are often hypoxic. The nurse should assess oxygen saturation to evaluate the possible cause if this occurs. The nurse may evaluate orientation, but the oxygen saturation is more important and should be performed initially. It is not necessary to notify the Rapid Response Team. A bronchodilator medication is not indicated.

The nurse is planning care for an 80-year-old long-term care patient who takes a histamine-2 blocker and who is confused most of the time. To help prevent pulmonary infection in this patient, which nursing action is included in the plan of care?

Assist the patient with all oral intake Rationale: Older patients who take H2 blockers (which increase gastric pH), and who are confused are at risk for health-care acquired pneumonia. The nurse should plan to supervise the patient while eating. Prophylactic antibiotics are only used when an actual threat of pneumonia is likely. Bronchodilator medications and postural drainage are treatments for symptoms of pneumonia and are not used prophylactically unless bronchospasm or secretions are present.

The nurse is teaching a patient newly diagnosed with tuberculosis (TB) about the medication and treatment regimen for this disease. What information does the nurse include when teaching this patient?

Avoid alcohol while taking medications unless provider says otherwise Rationale: Because many first-line medications for TB treatment can cause hepatotoxicity, the patient should be cautioned against consuming alcohol. It is not necessary to avoid exercise. The skin test is not used to evaluate the response to therapy; sputum specimens are evaluated every 2-4 weeks during drug therapy. Most patients require two to three medications to help combat both drug resistance and the disease.

Which mode of ventilation is suitable for a patient suffering from sleep apnea?

Bi-level positive airway ventilation (think BI-PAP) Rationale: Bi-level positive airway ventilation (BiPAP) provides noninvasive pressure support ventilation by nasal mask or face mask. It is most often used for patients suffering from sleep apnea. Flow-by ventilation is beneficial for patients in whom weaning from mechanical ventilation is needed. Assist-control ventilation continues to deliver a preset tidal volume, even when the patient's spontaneous breathing rate increases. Synchronized intermittent mandatory ventilation (SIMV) coordinates breathing between the ventilator and the patient and is not required in a patient with sleep apnea since continuous flow is needed.

Which new influenza strain has world health officials most concerned about becoming a pandemic?

Bird (avian) flu Rationale: The bird flu, or avian influenza, caused by the H5N1 virus strain is a current concern for world health officials. The H1N1 strain and Spanish flu viruses were pandemics in 2009 and 1918, respectively. The coronavirus is not an influenza virus strain and causes severe acute respiratory syndrome (SARS).

A patient has an endotracheal tube in place for mechanical ventilation. Which nursing action is most important to prevent infection in this patient?

Brushing the patient's teeth every 12 hours Rationale: A critical aspect of care to help prevent ventilator-associated pneumonia for patients with endotracheal tubes is meticulous oral care, including suctioning of the oral cavity, cleaning the tissues and gums with antiseptic agents, moisturizing the mucous membranes, and brushing the patient's teeth twice daily. Nurses should perform careful respiratory assessments to monitor for early signs of pneumonia, but these assessments are not preventive. Suctioning the ET tube and turning the patient are appropriate as well, but oral care is the most important nursing action.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalational anthrax. Which medications does the RN anticipate the health care provider will order?

Ciprofloxacin 400 mg IV every 12 hours Rationale: Intravenous ciprofloxacin is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (PZA) is used for treatment of tuberculosis.

Which manifestation in an older patient is the most common indicator for pneumonia?

Confusion

A patient with pneumococcal pneumonia is being treated with intravenous antibiotics. On the fifth day of treatment, the nurse notes a productive cough with white mucus. Which nursing action is correct?

Continue the current plan of care and reassess the patient periodically Rationale: The cough with pneumococcal pneumonia is typically productive of purulent rusty brown or yellow mucus; white mucus production indicates resolution of the infection. It is not necessary to administer a bronchodilator or a different antibiotic. The provider does not need to be notified.

A patient is receiving mechanical ventilation with FiO2 of 85%. The provider has ordered the positive end-expiratory pressure (PEEP) to be increased from 10 cm of H2O to 15 cm of H2O after the patient's oxygen saturation levels have remained less than 92%. As a result of this increase, which adjustment does the nurse plan to make?

Decrease the oxygen flow rate Rationale: PEEP is added when patients cannot maintain adequate gas exchange even with high-flow oxygen. The effect of preventing atelectasis should increase arterial blood oxygenation and allow the oxygen flow rate to be decreased. Adding PEEP does not have a direct effect on tidal volume, which is determined by the patient's weight and lung capacity.

Which intervention for a patient in the intensive care unit will decrease the incidence of "ICU psychosis?"

Decreasing nighttime disruptions

Which statement about pharyngitis is correct?

Development of stridor or indications of airway obstruction should be considered a medical emergency Rationale: Pharyngitis can lead to stridor and other indications of airway obstruction due to the swelling of the tissues; this can lead to a medical emergency requiring intubation if not identified early and treated urgently. Diphtheria is a bacterial infection, not viral. Organisms spread throughout the throat can actually be varied and thus a thorough throat culture is needed to facilitate accurate diagnosis. Viral and bacterial pharyngitis are difficult to differentiate on physical examination alone.

A patient who has been using a nasal decongestant spray to treat symptoms of rhinitis is experiencing severe rhinitis medicamentosa. The nurse notes significant nasal swelling and notifies the provider. Which treatment does the nurse expect the provider to order for this patient?

Discontinuation of the drug Rationale: Discontinuation of the drug is the treatment of rebound rhinitis caused by overuse of decongestant nasal drops or spray. Antihistamines, leukotriene inhibitors, and mast cell stabilizers are used to treat symptoms of allergic rhinitis.

A patient recovering from a pulmonary embolism after surgery is receiving low-molecular-weight heparin and warfarin. The patient's international normalized ratio (INR) is 2.4 today. After reporting this lab value to the provider, which order does the nurse anticipate?

Discontinue the heparin and continue the warfarin Rationale: The patient will typically take both drugs until the INR is between 2.0 and 3.0, then will stop taking the heparin. Patients may take warfarin for 3-6 weeks or indefinitely. There is no need to administer protamine sulfate or phytonadione, which are antidotes for heparin and warfarin, since the INR is within normal limits.

A patient with a pulmonary embolism has begun taking oral warfarin while still receiving intravenous heparin. The nurse notifies the provider that the patient has an international normalized ratio (INR) of 2.5. What order does the nurse anticipate?

Discontinuing the heparin Rationale: Patients who receive IV heparin for pulmonary embolism are usually started on an oral anticoagulant such as warfarin and continue on both until the INR is between 2.0 and 3.0. Once this is reached, the heparin can be discontinued. Vitamin K and protamine sulfate are antidotes for warfarin and heparin toxicity.

A patient being treated for a pulmonary embolism is receiving heparin, oxygen, and intravenous fluids. The nurse notes a persistent blood pressure of 88/58 mm Hg and a urine output of 20 mL/hr. Which medication does the nurse anticipate will be ordered by the provider?

Dobutamine Rationale: Patients who have persistent hypotension with a pulmonary embolism may be given an inotropic agent such as dobutamine to improve cardiac output. Vitamin K is the antidote for warfarin, protamine sulfate is the antidote for heparin, and aminocaproic acid is the antidote for fibrinolytic therapy.

A patient with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The patient is febrile and agitated. Which health care provider order should the nurse implement first?

Draw aerobic and anaerobic blood cultures Rationale: Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile patient for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this patient is a danger to self or staff, giving lorazepam for agitation is not the first action; the question indicates that the patient is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this patient is febrile and agitated, and a referral is not the immediate concern.

The nurse is caring for a patient who experiences a sudden onset of shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension. The nurse auscultates crackles in both lungs and assesses tachypnea and an oxygen saturation of 88%. After notifying the Rapid Response Team, what does the nurse do next?

Elevate the head of the bed and assemble oxygen delivery equipment Rationale: These are signs and symptoms of pulmonary embolism. The nurse's initial intervention after activating the Rapid Response Team will be to elevate the head of the bed and prepare to give oxygen. Heparin, venous access, chest x-ray, and telemetry require an order first. Reassurance and assessment of symptoms are ongoing.

A patient is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The patient calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes?

Ethambutol Rationale: Ethambutol can cause optic neuritis leading to blindness at high doses. When discovered early and when the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained, and oral contraceptives will be less effective.

Which symptom of pneumonia may present differently in the older adult than in the younger adult?

Fever Rationale: Older adults MAY NOT have a fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

The nurse is preparing to administer a trivalent influenza vaccine (TIV) to a 70-year-old patient with chronic obstructive pulmonary disease (COPD). While reviewing the patient's immunization record, the nurse notes that the patient received a pneumococcal polysaccharide vaccine (PPV23) 10 years prior. Which action does the nurse take?

Give the TIV and suggest that the patient receive a second PPV23. Rationale: There is some evidence that a second PPV23 is helpful for preventing pneumonia in patients with chronic lung disease if more than 5 years have passed since the initial PPV23. The nurse should suggest this to the patient or the provider. Administering the TIV and reminding the patient to receive this annually is correct, but the nurse should recommend a second PPV23 since this patient meets criteria for this booster. All patients over 50 years and those with chronic lung disease should receive the flu vaccine annually. Patients over 50 years of age cannot receive the live virus vaccine.

A clinic nurse is providing teaching for a patient who has been diagnosed with a peritonsillar abscess. What does the nurse include in this patient's teaching?

Go to the emergency department if drooling or stridor occurs Rationale: Patients with peritonsillar abscess should be taught the signs of airway obstruction that include drooling and stridor and should be told to seek emergency medical care if these occur. Tonsillectomy is sometimes necessary to prevent recurrence, but not always. Gargling with warm saline is a comfort measure and should be encouraged. Patients should be taught to take prescribed antibiotics for the full course of treatment and not to stop when symptoms subside.

Which actions known as the "ventilator bundle" have been shown to reduce the incidence of ventilator-associated pneumonia (VAP)? Select all that apply.

Hand hygiene Oral care Head-of-bed elevation Rationale: Hand hygiene, oral care, and head-of-bed elevation are the three interventions known as a "ventilator bundle" aimed at reducing VAP. Diligent oral care using agents to reduce organisms and provide moisture is especially important for nurses to perform to accomplish this goal. Monitoring for hypoxia and diligent equipment decontamination are indeed important in the care of the patient with pneumonia, but not "packaged" as part of the "ventilator bundle."

A patient with active tuberculosis is ordered to take isoniazid (INH), pyrazinamide (PZA), and rifampin (RIF) and asks the nurse why it is necessary to take three antibiotics. What is the nurse's best answer?

Helps prevent bacterial drug resistance Rationale: Multidrug therapy provides quicker destruction of organisms and combats drug resistance. It does not allow for lower dosing or decrease side effects. Taking these three drugs does not produce a synergistic effect.

A 70-year-old patient has a complicated medical history including chronic obstructive pulmonary disease (COPD). Which patient statement indicates the need for further teaching about the disease?

I am here to receive my yearly pneumonia shot again Rationale: Patients 65 years and older , as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, ONLY GIVEN ONCE, not annually. Older patients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention (CDC) for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation, and the nurse has an order to turn the patient every 2 hours. This action is performed to achieve which outcome?

Increase gas exchange (NOT to prevent pressure ulcers) Rationale: Positioning may be important in promoting gas exchange in patients with ARDS, but the exact position is controversial. Manually turning the patient every 2 hours has been shown to improve perfusion. Turning the patient does not affect lung compliance or reduce lung fibrosis. It does help prevent pressure ulcers, but in this patient's case, the order is given specifically to improve lung perfusion.

Incentive spirometry for the treatment of pneumonia has which outcome objective?

Increased inspiratory muscle action and decreased atelectasis Rationale: Incentive spirometry helps improve inspiratory muscle action and prevents or reverses atelectasis. It does not increase respiratory effort, reduce crackles and wheezes, or reduce sputum production.

A patient who is a lifetime smoker, obese, and has a previous history of thromboembolism is preparing to have major surgery that will require prolonged immobility. Past treatments with anticoagulant medications caused serious bleeding. Which management strategy will be best for this patient?

Inferior vena cava filtration Rationale: High-risk patients with a previous history of thromboembolism and bleeding with anticoagulant therapy can have a vena cava filtration device placed to prevent clots from reaching the lungs. Anticoagulant therapy is contraindicated in this patient because of the previous history of bleeding. Embolectomy is a surgical procedure to remove clots when a massive clot or multiple clots are present, causing shock. Fibrinolytic therapy also carries a risk for bleeding.

A patient sitting upright and receiving high-flow oxygen with a non-rebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The patient is using accessory muscles to breathe and appears fatigued. The nurse notifies the provider and prepares to receive an order for which intervention?

Intubation and mechanical ventilation Rationale: The patient is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this patient. A chest x-ray and arterial blood gases may be performed once the patient is stabilized as part of the ongoing assessment. An oral airway is used when the patient cannot maintain a patent airway. The head of the bed should be elevated to at least 30 degrees or higher if the patient prefers.

A patient is refusing to allow the nurse to apply pneumatic compression stockings while in bed, stating he doesn't like how they feel and they keep him awake. What is the nurse's best response?

It's important to wear them in bed so you don't develop a blood clot Rationale: The continuous use of antiembolism and pneumatic compression stockings is an essential intervention in the prevention of venous thromboembolism. Providing education to patients may help with their refusal to wear compression stockings.

The radiology report of a patient who has had a chest x-ray shows consolidation in a segment of the patient's left lung. This is typical of which type of pneumonia?

Lobar Rationale: Lobar pneumonia manifests as consolidation in a segment or an entire lobe of the lung. Bronchopneumonia manifests as diffusely scattered patches around the bronchi. While lobar pneumonia is generally bacterial, the pattern of lung involvement does not necessarily indicate the etiology.

In a patient with pneumonia, what is the most important nursing intervention?

Managing hypoxemia Rationale: Managing hypoxemia is the critical or priority action for nursing care of the patient with pneumonia. Although decreasing anxiety is important, it is not the priority. Preventing sepsis is important but not as urgent as managing hypoxemia. Teaching safe oxygen management would be more important if the patient was being discharged.

Which drug increases cardiac output by improving myocardial contractility?

Milrinone Rationale: Milrinone is a positive inotropic drug that increases the contractility of the cardiac musculature, thereby increasing cardiac output. Alteplase is a fibrinolytic drug that prevents the formation of clots in blood vessels. Nitroprusside is a vasodilator that is used for lowering blood pressure. Phytonadione is an antidote for warfarin and is administered in cases of warfarin overdose.

A patient taking antibiotics to treat rhinosinusitis reports facial pain over the affected sinuses. Which comfort measure does the nurse suggest in addition to the antibiotic therapy?

Moist heat over affected sinuses Rationale: Moist heat packs over the sinuses can alleviate some discomfort. Decongestant medications are also indicated. Frequent nose-blowing is not recommended. Patients should be taught to avoid placing the sinuses in a dependent position.

A patient who has begun standard multidrug treatment for tuberculosis (TB) reports orange-tinged sputum and urine. The nurse tells the patient that this symptom represents which response to the treatment regimen?

Normal drug side effects of rifampin Rationale: Orange-colored body secretions are an expected side effect of rifampin, one of the standard medications used for TB treatment. The orange color does not indicate spread of infection or hemolysis. Although alcohol and rifampin can cause hepatotoxicity, the orange color is not a sign of this complication.

The nurse is reviewing the following assessment data for a patient who was admitted after falling from a ladder and will be undergoing emergent surgery to stabilize a pelvic fracture. What is the nurse's priority intervention after assessing this patient? RR: 32 HR: 126 BP: 82/44 crackles pleural friction rub petechiae on right axillae Anxious, states that he feels like he will die Reports stabbing chest pain

Notify the Rapid Response team Rationale: This patient is showing classic signs of pulmonary embolism. The Rapid Response Team should be called to provide immediate support. Administering sedating agents may worsen the situation. Increasing the delivery of oxygen would provide little support. Massaging the lower extremities is contraindicated.

A postoperative patient exhibits a sudden onset of shortness of breath accompanied by syncope when getting up to a chair. The nurse assists the patient into the bed and performs an assessment which reveals a heart rate of 110 beats/min and a blood pressure of 88/56 mm Hg. The patient appears cyanotic and has distended neck veins. What is the nurse's first action?

Notify the rapid response team Rationale: A patient at risk for pulmonary embolism (PE) with the symptom cluster described should be assumed to have a PE and the Rapid Response Team should be called. Once this is done, the nurse should continue assessing the patient and administer oxygen.

A patient with acute respiratory distress syndrome (ARDS) is being mechanically ventilated. The provider has ordered 10 cm H2O of positive end-expiratory pressure (PEEP) to be used with mechanical ventilation. What assessment will inform the nurse that the PEEP was effective in supporting the patient's respiratory needs?

O2 sat increases from 85% to 92% Rationale: The patient with ARDS often requires intubation and mechanical ventilation with PEEP. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. An improvement in oxygen saturation would be used to evaluate the effectiveness of adding PEEP to the patient's mechanical ventilation mode.

The nurse is assessing a patient's risk for a venous thromboembolism (VTE). What are the major risk factors for VTE? Select all that apply.

Obesity Advancing age Prolonged immobility Rationale: In VTE, blood tends to clot in the veins. Obesity contributes to the deposition of cholesterol in the veins, leading to clot formation. The elasticity of veins decreases with age, which leads to clot formation. Prolonged immobility increases the risk of VTE due to venous pooling. Malnutrition and vitamin deficiency are not risk factors for VTE; they are not associated with functions related to blood vessels and blood clotting mechanisms.

Which group of individuals should be encouraged to receive the pneumococcal vaccine as an important health promotion and maintenance intervention?

Older adults with a chronic health problem Rationale: Individuals older than age 65, not 60, and those with chronic health problems should be encouraged to receive PPV 23 to prevent pneumonia. Since pneumonia often follows influenza among older adults, these individuals should also be encouraged to receive the seasonal influenza vaccination yearly. Although many individuals who develop ventilator-associated pneumonia (VAP) are older individuals with chronic illnesses, VAP in a younger individual is not a primary indication for pneumococcal vaccine.

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

Shortness of breath, chest pain, and tachycardia indicates...

PE Rationale: Difficulty breathing, tachycardia, chest pain, fainting, and cyanosis are some of the common clinical manifestations of a pulmonary embolism. The patient also has experienced two of the major risk factors—bone fracture and surgery. A pulmonary infection and edema can cause breathing difficulties and possible cyanosis, but usually not fainting or chest pain. Respiratory difficulties and chest pain are not usual reactions to anesthesia.

A patient has developed a pulmonary embolism. The nurse anticipates orders for which lab values before beginning heparin therapy for this condition?

PTT Rationale: A baseline PTT should be obtained before the administration of heparin. The other actions are also important to take for the patient with a pulmonary embolus but do not have to be done before heparin administration. Kidney function tests are not indicated for this patient.

Which assessment finding best indicates that the endotracheal tube remains correctly placed in the patient's trachea and is not in the esophagus?

Paco₂level is 38 mm Hg Rationale: The Paco2level is normal. If the endotracheal tube was in the esophagus or stomach rather than the trachea, the Paco2level would be below normal (i.e., less than 35 mm Hg). The fact that air cannot be heard in the stomach or that a suction catheter is easily passed are not conclusive assessments of a correctly placed endotracheal tube. The oxygen saturation is also not the best assessment parameter for determining endotracheal tube placement.

What is a key difference between seasonal influenza and pandemic influenza?

Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans Rationale: Mutated animal and bird viruses can be highly infectious to humans and spread globally very quickly because humans have no natural resistance to the mutated virus. Both seasonal and pandemic influenza are caused by viruses. Although there is the potential to develop a monovalent vaccine to a given mutated virus, widespread prophylactic vaccination is not realistic as a preventive measure. People over age 50 with chronic illnesses and those who are immunocompromised should receive a yearly flu vaccine for the seasonal variety.

The nurse is teaching the family of a patient who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?

Paralysis and sedatives help decrease the demand for oxygen Rationale: Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the patient from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.

Which critically ill patient has the greatest risk for developing acute respiratory distress syndrome (ARDS)?

Patient with aspiration pneumonia Rationale: Aspiration of acidic gastric contents is a risk for ARDS. Patients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

Which of these patients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit?

Patient with pulmonary TB who is receiving multiple medications Rationale: The LPN/LVN scope of practice includes medication administration, so a patient receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this patient needs to be managed by the RN. A patient in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A patient with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN.

The nurse hears the ventilator alarm come from the room of a patient who is receiving mechanical ventilation. When arriving in the patient's room, which assessment does the nurse perform first?

Patient's color, perfusion, and chest rise Rationale: The first assessment should always be the patient and not the ventilator or the monitor readings.

The nurse is counseling a patient whose parent has just been diagnosed with tuberculosis (TB). The patient tells the nurse that the parent was exposed several years ago, but developed symptoms only recently. What does the nurse tell this patient about his or her risk of contracting the disease?

People are only infectious to others when symptoms are present Rationale: It is important to remind patients that people with TB are infectious only when manifestations of the disease occur. Patients being treated for TB are not considered contagious after 2-3 weeks of drug therapy. The only way to diagnose TB is with testing and by evaluation of symptoms. Treatment is initiated when the disease is confirmed.

What could be the possible diagnosis for a patient who presents with pain in the throat, difficulty swallowing, swelling in the throat, and difficulty in opening the mouth?

Peritonsillar abscess Rationale: Pain and difficulty swallowing, swelling of the throat, and difficulty in opening the mouth are symptoms of peritonsillar abscess, a complication of acute tonsillitis. Pain and difficulty swallowing and swelling of the throat are also common symptoms of tonsillitis, pharyngitis, and retropharyngeal abscess; however, difficulty in opening the mouth is not associated with these conditions.

A patient who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action?

Place a respiratory mask on the patient Rationale: The concern is that this patient has TB. A respiratory mask should be placed on the patient immediately. Requesting medications for TB is not appropriate until the patient has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the patient know that results will not be available for at least 48 hours after the test is administered. Further testing of this patient needs to be completed and a diagnosis made before family members are tested.

The nurse receives a report about a patient with chronic obstructive pulmonary disease (COPD) and learns that the patient has orthopnea. The nurse plans to perform which comfort measure for this patient?

Place the patient in an upright position to facilitate breathing. Rationale: Patients who have orthopnea have increased dyspnea when lying down and should be placed in an upright position to facilitate breathing. Dyspnea that occurs with exercise may be managed by a gradual increase in activity. The patient with orthopnea is not necessarily hypoxic and does not need oxygen unless oxygen saturation or blood gas measures indicate hypoxia. Patients who have wheezing may need bronchodilator therapy.

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.

A patient returns to the clinic to have the tuberculosis (TB) Mantoux test analyzed by the nurse, which was administered 2 days ago. The patient's left forearm shows a red raised area, which measures 10 mm in diameter. How does the nurse document this finding?

Positive reaction that indicates exposure to and the possible presence of TB infection Rationale: An area of induration (raised soft tissue) measuring 10 mm or greater in diameter at 48-72 hours after the injection indicates exposure to and possible infection with TB. A positive reaction does not in itself mean TB is present until that has been confirmed with a chest x-ray and sputum culture. There are no false-positive readings, but the incidence of false-negative readings is greater at 48 hours and will need to be read again at 72 hours to confirm. The test will not be administered again in this situation.

The nurse assesses extreme shortness of breath, agitation, and apprehension in a patient who had knee surgery. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. The nurse suspects which postoperative complication?

Pulmonary Embolism Rationale: The patient's history and clinical manifestations suggest that a pulmonary embolus may have occurred. Anaphylaxis and bronchospasm are characterized by wheezing. Pneumothorax is characterized by absent breath sounds on the affected side.

A patient recovering from an osteotomy and pin fixation for a femur fracture suddenly experiences shortness of breath, chest pain, and tachycardia. What does the nurse suspect is causing the patient's symptoms?

Pulmonary embolism Rationale: Difficulty breathing, tachycardia, chest pain, fainting, and cyanosis are some of the common clinical manifestations of a pulmonary embolism. The patient also has experienced two of the major risk factors—bone fracture and surgery. A pulmonary infection and edema can cause breathing difficulties and possible cyanosis, but usually not fainting or chest pain. Respiratory difficulties and chest pain are not usual reactions to anesthesia.

A patient who had knee replacement surgery 2 days ago has a sudden onset of dyspnea and cough and reports a sharp, stabbing pain in the chest. The nurse notes a heart rate of 110 beats/min, bilateral crackles in lung fields, and an oxygen saturation of 97% on room air. Which postoperative complication does the nurse suspect the patient has developed?

Pulmonary embolism Rationale: The patient has symptoms of a pulmonary embolism, which DO NOT ALWAYS include hypoxemia. Patients with atelectasis and pneumonia would likely have diminished breath sounds. Deep vein thrombosis may have preceded the pulmonary embolism.

A patient with pneumonia develops increased fever, chills, and night sweats. The nurse auscultates decreased breath sounds in the right lung and observes decreased chest wall movement in that area. The nurse reports these findings to the provider and suspects which secondary infection has likely developed?

Pulmonary empyema Rationale: These are signs of pulmonary empyema, an infection in the pleural space. A fungal infection may occur anywhere, often as an abscess in the lungs, which is characterized by fever, cough, and foul-smelling sputum. Tuberculosis is characterized by cough and blood-tinged sputum.

A patient is receiving mechanical ventilation after developing acute respiratory distress syndrome (ARDS) from aspiration pneumonia. The patient's spouse asks the nurse how long it will take the patient to recover. How does the nurse respond?

Recovery time depends on the severity and progression of symptoms Rationale: Patients with ARDS have a poor survival rate, but some do recover. The phase of symptoms that each patient develops is somewhat predictive of survival rate. Patients who progress to stage 4 usually have permanent lung damage and often are ventilator-dependent. The best answer is to tell the family member that the severity and progression of symptoms can indicate recovery chances.

An older patient has a persistent cough with hemoptysis and has a known exposure to tuberculosis. A tuberculin skin test reveals a reaction less than 5 mm. The nurse documents that this test result indicates which condition?

Reduced immune function Rationale: Patients with reduced immune function may have a negative skin response even when infected with tuberculosis. This can occur in older adults as well as people who are HIV positive. The negative skin test only represents reduced immune function and does not always indicate HIV. This result does not indicate latent TB or immunity to TB.

The nurse expects which changes in a patient with acute respiratory distress syndrome (ARDS)? Select all that apply.

Reduction in surfactant activity Damage to type II pneumocytes Edema around terminal airways Rationale: ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged, and edema forms around terminal airways. Surfactant activity is reduced due to the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases, and edema forms around terminal airways. In ARDS, lung volume is decreased and lung channels are compressed.

Which intervention will be most effective in reducing anxiety in a patient with a pulmonary embolism (PE)?

Remain with the patient and provide oxygen in a calm manner Rationale: The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the patient in distress is appropriate. Rebreathing from a brown bag is an intervention that increases Paco2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the patient but will not improve oxygenation.

Which upper respiratory infection is often triggered by a hypersensitivity reaction to airborne allergens?

Rhinitis Rationale: Allergic rhinitis (hay fever or allergies) is triggered by a hypersensitive reaction to airborne allergens, especially plant pollens or molds. These infections can occur in the sinuses (sinusitis) or throat (pharyngitis); however, the initial trigger is the hypersensitive allergic reaction. Tonsillitis is a contagious airborne infection that has settled in the tonsils on either side (or both sides) of the throat.

A patient with nasal congestion, fever, and cough has been using over-the-counter medications for a week without improvement. The patient exhibits tenderness to percussion over the sinuses and referred pain to the back of the head. These findings may indicate which condition?

Rhinosinusitis Rationale: Prolonged upper respiratory symptoms can indicate that a sinus infection has developed. Tenderness to percussion over the sinuses and referred pain to the back of the head are common manifestations of rhinosinusitis. Manifestations of rhinitis include headache, nasal irritation, sneezing, nasal congestion, rhinorrhea, and itchy, watery eyes. The patient with pharyngitis has throat soreness and dryness, throat pain, odynophagia, difficulty swallowing, and may have a fever. Tonsillitis is manifested by a sudden sore throat, fever, muscle aches, chills, and dysphagia. The tonsils are visibly swollen and red.

Which symptom indicates that a patient's pharyngitis is most likely bacterial and not viral?

Scarlatiniform rash Rationale: Dysphagia, dull tympanic membranes, and lymphadenopathy may all be present with viral or bacterial pharyngitis. A scarlatiniform rash is only present with bacterial pharyngitis.

A previously infected patient with a dormant tuberculosis (TB) infection has experienced a reactivation of the disease. Which was likely a factor in this occurrence?

Taking prednisone for the last 3 weeks Rationale: Secondary TB is reactivation of the disease in a previously infected person. This most likely happens when the immune system is lowered, as occurs with corticosteroid drugs such as prednisone, which suppress the immune response. Allergy testing, receiving a vaccination, and fracturing a rib would not suppress the immune system enough to reactivate the disease.

A 55-year-old patient asks the nurse about getting the live attenuated influenza vaccine instead of the trivalent influenza vaccine. What does the nurse tell this patient?

The live attenuated influenza vaccine (LAIV) is not recommended for you Rationale: LAIV is not given to patients age 50 and older, so this patient is only eligible for the trivalent influenza vaccine (TIV). The LAIV can cause flu symptoms in recipients.

The nurse is overseeing a nursing student who is administering medications to a group of patients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about heparin therapy?

Therapy with warfarin is effective when your INR is between 2 and 3 Rationale: The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

The nurse is caring for a patient who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this patient?

Use of aspirin and salicylates Rationale: Use of aspirin and salicylates will prolong the INR and cause gastric irritation. Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR. A prolonged expiratory phase is typical in chronic obstructive pulmonary disease (COPD), not GI bleeding or a prolonged INR. Massaging the calves may present a risk for PE if deep vein thrombosis is present but does not relate to GI bleeding and prolonged INR.

The nurse assesses a patient with asthma who exhibits wheezing, dyspnea, and intercostal retractions during an acute exacerbation. An arterial blood gas shows Pao2 of 55 mm Hg, a Paco2 of 50 mm Hg, and a pH of 7.25. What is this patient experiencing?

Ventilatory and oxygenation failure Rationale: Patients with chronic obstructive diseases such as asthma will develop oxygenation failure because of diseased airways and subsequent increased work of breathing that progresses to ventilatory failure. This patient is not compensating as evidenced by hypercapnia and hypoxia and acidosis.

Dysphagia, odynophagia, negative throat culture, and WBC count of 9,000/mm3 confirms the diagnosis as __________________

Viral pharyngitis Also: The WBC count would be greater than 12,000/mm3 to CONFIRM a diagnosis of viral pharyngitis.

The nurse is caring for a patient with severe acute respiratory syndrome (SARS). What is the most important precaution the nurse should take when preparing to suction this patient?

Wear a particulate mask respirator and protective eyewear Rationale: To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head or the bed elevated 30-40 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

A patient is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan?

You will need to have your household undergo TB testing Rationale: The people the patient has been living with have already been exposed and need to be tested. They cannot be reexposed simply because the diagnosis has now been confirmed. The patient with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

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 (normal) INR is between 2 and 3 (on warfarin) 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.