NRSG 337-Exam 2

Post-op Day 0: incision slightly edematous and warm, no drainage, mild pain, temp 98.8 Which one is the cause? A. Inflammation B. Infection-related inflammation c. Uncertain

A. Inflammation Rationale: These manifestations are all consistent with a normal inflammatory response due to tissue injury. In this case, the "injury" was the surgical procedure.

Vital signs obtained by you, the triage nurse, are as follows: •BP 96/72; HR 120; RR 26; O2 sat 92% on room air; temp 102.6 F You immediately assign Polly to an ED bed based on knowledge that she is at highest risk for sepsis related to A.Immunosuppression B.Pyelonephritis C.Diabetic ketoacidosis D.Hyperlipidemia

A. Immunosuppression

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement best indicates the client comprehends the teaching? "I will be weaned off this medication when I no longer need it." "I should not use this medication with prescribed inhaled corticosteroids." "I will take this medication every morning to help control my COPD symptoms." "I will take this medication on days I feel short of breath."

"I will take this medication every morning to help control my COPD symptoms."

While providing drug education to the client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide for the treatment of pulmonary tuberculosis, which priority education point will the nurse stress with the client? "It is important to take these drugs exactly as ordered." "If you miss a dose, take a double dose the next time." "These drugs will help to kill the germs in your lungs." "Take the drug doses at bedtime to decrease nausea."

"It is important to take these drugs exactly as ordered."

The ED physician reviews your data collection and examines Polly. The following orders are written: A.STAT basic metabolic panel, CBC, liver function tests, lactate level, blood cultures × 2, urinalysis, urine culture and sensitivity (C&S), sputum C&S, arterial blood gases (ABGs), prothrombin time/international normalized ration (PT/INR), activated partial thromboplastin time (aPTT). B.Chest x-ray C.Oxygen 2 L via nasal cannula PRN to keep O2 saturation >92% D.Ceftriaxone 2 grams IV every 12 hr E.Initial fluid bolus of 30 ml/kg of normal saline IV wide open F.Insert urinary catheter to monitor output G.Prepare for insertion of central line for CVP monitoring In what order and timeframe will you implement the orders?

(Assuming the health unit coordinator is entering the STAT orders): 1.Oxygen (ABCs: support tissue oxygenation during this situation that we know involves more oxygen demand than the body can supply due to all the inflammatory changes affecting circulation) 2.IV and start fluids (ABCs: BP is low and we need to support circulation) 3.Ensure lab comes for cultures ASAP (will collect the other samples at the same time; try to get sputum, but don't delay antibiotics if unable to produce sample once other cultures collected) 4.Start antibiotics within the hour (once as many cultures as possible have been collected; for example, patients cannot always produce sputum, in which case we would not delay starting antibiotics) 5.Foley (could start sooner if waiting for lab or if patient cannot urinate; otherwise, this can be deferred until the higher priority items are done) 6.Ensure x-ray has come (may arrive sooner; x-ray will not be affected immediately upon administration of antibiotics like culture will, so it is okay to fit it in/keep it lower priority).

Determine if each of the listed nursing interventions is indicated or contraindicated for the patient. •T = 100.6 F (38.1 C) •BP = 118/64 •P = 70 •RR = 18, shallow •O2 Sat = 93% (2 L/min via nasal cannula) •Heart sounds: Regular Lung sounds: Diminished with crackles bilaterally in the bases at the end of inspiration •Bowel sounds: Present •Skin: Intact and free of redness •Pulses: 2+ •Pain: 7/10 Potential Nursing Intervention: Indicated or Contraindicated? 1-Cough and Deep Breathe 2-Provide chest physiotherapy every 30 minutes to 1 hours 3-Incentive Spirometry every 1-2 hours while awake 4-Administer 0.5 hydromorphone by mouth as ordered 5-Administer 20 mg IV Furosemide

1-I 2-C 3-I 4-I 5-C Patient is exhibiting s/sx consistent with atelectasis. We need to have the patient cough/deep breathe and use the incentive spirometer. This may resolve these symptoms. In order to accomplish this, we need to control his pain. If his oxygen saturation does not increase and his temp and the crackles do not resolve, something else may be occurring, necessitating a call to the provider. IV lasix contraindicated chest physiotherapy every 30 minutes to one hour is contraindicated (too frequent) Note that in order to accomplish the above, we will need to use therapeutic communication and establish a trusting relationship. This will support having a meaningful conversation about the importance of "pulmonary toilet" (a fun old term for using incentive spirometer, C/DB, and position changes to support respiratory system) and pain control (pain control should help compliance with "pulmonary toilet").

Susan, a 55 y/o female, is admitted with warm, red, swollen, deformed joints and uncontrolled pain. She has severe rheumatoid arthritis and had an upper GI bleed 5 years ago. •Vital signs : BP: 128/60, HR: 98, RR: 16, Temp: 99°F, O2 Sat of 95% on room air. •Medications: famotidine 20 mg/day and prednisone 5 mg/day. She has also been taking 800mg of ibuprofen 3x/day to try to get control of the pain. 1.Identify the manifestations of inflammation in the patient. 2.Categorize this patients' type of inflammation. A.Acute B.Sub-acute C.Chronic 3.What initial assessment information needs follow-up by the nurse? 4.What priority nursing problems do you plan to address?

1. Warm, red, swollen, painful joints.; slight temp 2. Chronic inflammation with acute exacerbation 3. Uncontrolled pain; taking large amounts of ibuprofen with a history of GI bleeding; also concerned about increased risk for infection due to prednisone and uncontrolled pain 4. Pain; impaired mobility; risk for infection; risk for bleeding; knowledge deficit

Shen's chest x-ray and sputum smear for AFB confirm the TB diagnosis. 1.What treatment would you expect the health care provider to order for Shen? A.Isoniazid B.Intradermal Mantoux C.Piperacillin and tazobactam IV D.Isoniazid, rifampin, pyrazinamide, and ethambutol 2.Do you think Shen needs to stay in the hospital at this point? A.Yes B.No 3.What patient teaching should you do with him?

1.A four-drug therapy regimen of isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol. •Latent infection: one or two drugs for multiple months •TB disease (active): two phases of multi-drug therapy over multiple months 2.Yes: although most people do not need hospitalization , Shen's history and living situation do not provide an optimal place for him that supports treatment 3.Teaching (some are general and not specific to Shen): •Patients and families should be educated about the importance of medication compliance and the basic principles of infection control: covering the mouth when coughing or sneezing, disposing of tissues in plastic bags, practicing good hand hygiene, and wearing a mask when in contact with crowds until medication effectively suppresses the infection. Sputum examinations are required monthly during treatment. •When sputum cultures are negative and the clinician evaluates the effectiveness of the treatment, the patient is considered no longer infectious and may resume work and other usual social activities. •Close contacts are monitored with skin or blood testing. If the TST or IGRA result is positive, the contact is treated with INH, RPT, or RIF depending on whether the type of TB is known to be drug resistant. HIV-positive, pregnant, or breastfeeding individuals as well as infants and children have specific recommended drug combinations and doses. The CDC website has the most current treatment recommendations. •Promotion of immunity •Improving living conditions and carrying out sound health practices are essential to maintaining a natural resistance to TB. The populations most at risk for contracting TB are those with an insufficient immune system. That is why the very young and the very old as well as those with immunosuppression from disease or disease treatment are at increased risk. •It is also important that the patient name all close contacts, so that they can be notified and appropriately tested and treated. Giving the names of contacts may be very difficult for the patient because of the social stigma that is still attached to TB in certain cultural groups. •Directly observed therapy (DOT) may be recommended. DOT involves visual observation of the ingestion

•What assessment findings would you expect?

1.Activity intolerance, fatigue, pale skin, cold hands and feet, dizziness, shortness of breath, chest pain if severe

Case Study John, a 22 y/o male, enters the ED with c/o right ankle pain sustained while playing volleyball. He reports he stepped on another player's foot, inverting his ankle. 1) How would you categorize this patient's type of inflammation? A. Acute B. Subacute C. Chronic 2) What are your priority assessments upon assuming care of this patient?

1.Acute inflammation 2.The patient reported how the injury occurred, implying ABCs are intact at the moment. Therefore, assessing the affected extremity is the priority: 1.Site of injury A.CMS assessment of the affected extremity distal to the site of injury (Circulation: color, cap refill, pulses, temp; Motion; Sensation: numbness; parasthesias) B.Also: Is skin intact and is ther any displacement that would indicate a fracture? 2.Additional priorities: •Assess vitals •Assess other systems to ensure no other injuries have occurred (i.e., did the patient fall and hit is head after inverting his ankle?) •Pain •Medical history including allergies and meds

Donna is an 88-year-old woman who lives alone. She has been feeling weaker over past 2 days. Last night became confused and disoriented. Her housekeeper notified her daughter, who brought Donna to the clinic. She complains of coughing over the past 3 days. She has a history of mild heart failure that is treated medically but has no other significant health disorders. She last saw her health care provider 4 months ago. 1.What are Donna's risk factors for pneumonia? 2.What clinical manifestations of pneumonia is Donna displaying?

1.Age, limited mobility, chronic heart failure 2.Cough, weakness, confusion Note that additional manifestations could include the following: Shaking chills; dyspnea; tachypnea; pleuritic chest pain; green, yellow, or rust-colored sputum; rhonchi and rales; bronchial breath sounds; egophony; ↑ fremitus; dullness to percussion if pleural effusion present; nonspecific manifestations including diaphoresis, anorexia, fatigue.

Shen is a 57-year-old Chinese man who was transported from a homeless shelter for having respiratory symptoms. He has a history of IV drug use and is HIV positive. He has been coughing regularly and producing mucopurulent sputum. 1.What risk factors does Shen have for TB? 2.What diagnostic tests would you expect the healthcare provider to order for Shen?

1.Homeless, IV-drug user, resident of a shelter, poverty, Asian descent, immunosuppression (HIV) 2.Tuberculin skin-test (TST) or interferon-γ release assay (IGRA), chest x-ray, sputum c&s, sputum for acid fast bacilli

•What are possible interventions may be needed?

1.Mild: increase dietary intake of iron; moderate: oral iron supplements to possibility of IM or IV iron; severe: administration of blood. Other causes may result in other treatments. Example: anemia caused by renal disease may necessitate erythropoietin injections (healthy kidneys make the RBC stimulating hormone).

Place an X next to the best indicators showing the disease is beginning to resolve. Options: 1. Tolerating nebulizer treatments 2. Fewer adventitious sounds in lungs 3. WBCs decreasing 4. Tolerating antibiotics without side effects 5. Walking short distances in hall without SOB 6. Pulse oximetry consistently 96% 7. Chest x-ray indicates less density 8. Removing oxygen cannula for meals

2, 3, 5, 6, 7 Correct responses: Fewer abnormal breath sounds, less density on the x-ray, and decrease in white count are all objective signs that the pneumonia is resolving. The presence of these findings are what lead to the pneumonia diagnosis, so the diminishing of these findings indicate that the patient is getting better. Ability to ambulate without shortness of breath indicates lung function has improved Although it is hoped that the patient can tolerate nebulizer treatments and not have medication side effects, these are not measures of resolution of the pneumonia. Removing the cannula for meals does not help with assessing improvement unless additional assessments that indicate an improved activity tolerance are made.

Which assessment finding would the nurse expect when caring for a patient admitted with chronic obstructive pulmonary disease (COPD)? Increased oxygen saturation with exercise A hyperinflated chest on the chest x-ray Hypocapnia A bloody, productive cough

A hyperinflated chest on the chest x-ray

The nurse is most concerned about risk for infection related to a decreased inflammatory response for which of the following patients? A patient who recently experienced a stress fracture of the left foot. A patient with gallstones who is scheduled for a laparoscopic cholecystectomy in 2 weeks. A patient who has been receiving oral corticosteroids. A patient whose hemoglobin is 13.1 mg/dL.

A patient who has been receiving oral corticosteroids.

The nurse cares for a patient with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this patient's history and clinical manifestations? A. Increased pulmonary pressure creating a higher workload on the right side of the heart (Cor pulmonale). B. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles. C. Increased number and size of mucous glands producing large amounts of thick mucus. D. Left ventricular hypertrophy creating a decrease in cardiac output.

A. Increased pulmonary pressure creating a higher workload on the right side of the heart (Cor pulmonale).

Your patient, who is post-op from a gastrointestinal surgery is presenting with a temperature of 103.6'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings indicate that the patient is progressing to septic shock? Select all that apply. A.Blood pressure of 70/34 after the fluid bolus B.Serum lactate is greater than 2 mmol/L C.White blood cell count of 6500 D.Urine output is 20 mL over 2 hours. E.Glasgow coma scale score of 12

A, B, D, E A.Blood pressure of 70/34 after the fluid bolus B.Serum lactate is greater than 2 mmol/L D.Urine output is 20 mL over 2 hours. E.Glasgow coma scale score of 12

The nurse is teaching a patient with a new prescription for salmeterol (Serevent). Which statement by the patient indicates a need for additional teaching? A. "I will use the drug immediately if I experience an asthma attack." B. "I will be careful not to let the drug escape out of my nose and mouth." C. "I will be certain to shake the inhaler well before I use it." D. "It may take a while before I notice a change in my asthma."

A. "I will use the drug immediately if I experience an asthma attack."

Which assessment findings would the nurse expect when caring for a patient admitted with chronic obstructive pulmonary disease (COPD)? A. A hyperinflated chest noted on the chest x-ray B.Increased oxygen saturation with exercise C.A bloody, productive cough D.Hypocapnia

A. A hyperinflated chest noted on the chest x-ray

The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A. A patient sitting in tripod position with a respiratory rate of 34/min. B. A patient with diminished lung sounds on auscultation. C. A patient with jugular vein distention and peripheral edema . D. A patient who has a cough productive of thick, green mucus.

A. A patient sitting in tripod position with a respiratory rate of 34/min. The RR of 34 indicates respiratory compromise (critically elevated; this patient could fatigue quickly, progressing to acute respiratory failure). The last three options do not provide data that indicates the patients are in distress (B = expected with COPD: C= expected with cor pulmonale- a potential complication of COPD; D = expected with a respiratory infection which is a common reason for COPD-related admissions and the patient is successfully clearing secretions)

The nurse realizes that Donna most likely has A. Community acquired pneumonia B. Opportunistic pneumonia C. Viral pneumonia

A. Community acquired pneumonia Community acquired pneumonia. Rationale: living in community; has not been in the hospital or residing in an institution; bacteria seen on gram stain [so not viral]; no conditions that cause immunosuppression [so not opportunistic]

A patient has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? A. Educating the patient on adherence to the treatment regimen. B. Teaching the patient ways to balance rest with activity. C. Informing the patient about follow-up sputum cultures. D. Encouraging the patient to eat a well-balanced diet.

A. Educating the patient on adherence to the treatment regimen.

The nurse is caring for a patient with a suspected infection. The provider has ordered broad-spectrum IV antibiotics. Which action does the nurse prepare to do first? A. Obtain blood cultures. B. Request an order for a chest x-ray. C. Administer antibiotics. D. Administer an antipyretic.

A. Obtain blood cultures.

A patient experiencing a severe acute asthma attack received a short-acting beta-adrenergic agonist by nebulizer. Which assessment finding would indicate to the nurse that the treatment is having a therapeutic effect? A. Peak expiratory flow increased from 50% to 70% B. Reduced air movement is auscultated in the lung fields C. Use of accessory muscles during inhalation D. SpO2 decreased from 85% to 83%

A. Peak expiratory flow increased from 50% to 70%

A patient reports sudden onset of chest pain and shortness of breath. Assessment reveals absent lung sounds on the right side. Which pulmonary disorder does the nurse most suspect? A. Pneumothorax B. Pleurisy C. Respiratory failure D. Atelectasis

A. Pneumothorax (collapsed lung)

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? A. Pulse rate of 72 beats/min B. Temperature of 98.4°F C. Respiratory rate of 18/breaths/min D. Oxygen saturation 96%

A. Pulse rate of 72 beats/min

The nurse is preparing to provide dietary teaching to a client with iron deficiency anemia. The patient reports being a vegetarian who does not eat meat products. Which foods should be included in the diet teaching? A. Spinach and egg yolks B. Citrus fruits and strawberries C. Cheese and whole milk D. Iceberg lettuce and almonds

A. Spinach and egg yolks

When educating a young adult about possible triggers for an asthma attack, which response indicates the client needs further teaching? (Select all that apply) A."I can take any over the counter medications." B."I don't need to avoid alcohol because it doesn't affect asthma." C."I should avoid being around second-hand smoke." D."Animal dander can increase my chances of triggering my asthma."

A."I can take any over the counter medications." B."I don't need to avoid alcohol because it doesn't affect asthma."

A patient is admitted with sepsis. Skin is cool and pale, capillary refill is prolonged, and pulse is weak and rapid. Which intervention should be the priority action by the healthcare provider? A.Establish vascular access B.Calculate the mean arterial pressure C.Take a complete set of vital signs D.Draw blood for a complete blood count

A: Establish vascular access (rationale: the assessment data in the stem tells you the patient has impaired circulation and perfusion: cool pale skin, delayed cap refill, weak and rapid pulse. This is enough concerning data to know action is needed to preserve circulation. A full set of vitals will delay that action. Get IV access and then get the full set of vitals at which time you'll be able to calculate the mean arterial pressure. The CBC option is also of lower priority based on A-B-C.)

Case Study: Anemia You are caring for Margaret Johnson who experienced a post-op hemorrhage following a colon resection yesterday. It is estimated she lost 1500 mL of blood. Her hemoglobin was 12.1 mg/dL on admission. Today it was 8.8 mg/dL. •What is the main pathophysiological consequence of anemia?

Anemia decreases oxygen carrying capacity. This decreases oxygen delivery to cells. Cell demand for oxygen may exceed supply. Cells may become hypoxic and be damaged or even die which can lead to organ dysfunction.

A nurse manager is concerned about the number of infections on the hospital unit. What action should the nurse manager take first? Teach staff members about droplet isolation precautions Ensure influenza-positive clients are placed in appropriate isolation Establish a policy to remove urinary catheters quickly Audit staff members' hand hygiene and infection control practices

Audit staff members' hand hygiene and infection control practices

A. Activity Intolerance B. Impaired Gas Exchange C. Ineffective Airway Clearance Match the defining characteristics below with the best nursing problem above: A.Adventitious breath sounds B.Chronic fatigue with activity C.Dyspnea on exertion D.Hypercapnia and hypoxemia E.Ineffective, loose cough F.Expiratory airflow obstruction G.Cyanosis H.Low oxygen saturation

Activity Intolerance •Chronic fatigue with activity •Dyspnea on exertion Impaired Gas Exchange •Hypercapnia and hypoxemia •Cyanosis •Low oxygen saturation Ineffective Airway Clearance •Ineffective, loose cough •Expiratory airflow obstruction •Adventitious breath sounds

The nurse is caring for a patient with active tuberculosis. Which isolation precaution category should be used? Airborne Environmental Droplet Contact

Airborne

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A.Ask the patient whether medications have been taken as directed. B.Discuss the need to use some different medications to treat the TB. C.Schedule the patient for directly observed therapy(DOT) three times weekly. D.Educate about using a 2-drug regimen for the last 4 months of treatment. When a patient is on medication treatment for TB, liver enzymes should be monitored.

Answer = A: ask the patient whether medications have been taken as directed considering adherence challenges with TB treatment, "A" is an important assessment and should be made before progressing to the other options.

The nurse is teaching a patient who has been advised to increase dietary consumption of iron and take an over-the-counter iron supplement due to anemia. Which statement by the patient would indicate a need for more teaching? A."I will consume foods high in iron and take iron supplements with foods high in ascorbic acid (vitamin C) to increase absorption." B."I will take my iron supplements when feeling fatigued or weak." C."Iron supplements may cause GI upset. I will take them with food if that happens." D."Iron supplements may turn stools black." E."Foods high in iron include muscle meats, dark green leafy vegetables, dried fruits, and legumes."

Answer = B ("I will take my iron supplements when feeling fatigued or weak."): iron should be taken consistently, since its effects are not immediate; the supplement must be absorbed and then used to generate new red blood cells which take time to mature. The other options are correct. Iron supplements are best taken on an empty stomach for optimal absorption. But, if GI upset occurs, take with food (better to have some absorbed than none). Take iron supplements or eat high iron foods along with foods high in ascorbic acid (example: orange juice) to increase absorption. Do not take with milk, calcium, or antacids (will bind). Iron may turn stools black which is okay (however, any s/sx of blood in stool, including black tarry stools, should be reported). Iron may be constipating (teach constipation prevention interventions: increase activity, fluid consumption, fiber consumption). Teach the patient about foods high in iron, such as muscle meats, dark green leafy vegetables, dried fruits, and legumes.

An older client has been admitted to the acute care medical unit with a community acquired pneumonia. The client was alert and oriented x3 eight hours ago but is now disorientated to person and place and appears restless. What action should you take next? A.Call the health care provider. B.Check a pulse oximetry reading. C.Assess the client for pain or discomfort. D.Perform a full neurological assessment.

Answer is B(Check a pulse oximetry reading) change in mental status could indicate hypoxia

The nurse is caring for a patient who was admitted 6 days ago for urosepsis. The CNA reports the patient has had three watery stools this shift. Which action should the nurse take first? A.Teach about the importance of fluid intake to prevent dehydration. B.Initiate contact precautions. C.Request an order for a stool culture. D.Inspect skin integrity around the rectal and anal opening.

Answer: 1. B: Need to initiate contact precautions (rationale: have reason to suspect c-diff) 2. C: Get order for stool culture and collect. 3. D: Assess skin integrity 4. A: Teach about how to prevent dehydration ***Be sure to explain what you are doing and why to your patient.

Case Study continued.... •VS: 124/76 (BP), 82 (HR), 18 (RR), 98.2 (T) •Redness and swelling over the lateral malleolus down to the fourth and fifth metatarsals, pedal pulse +2, skin pink with capillary refill of 2 seconds, + mvmt of toes, no numbness, sensation intact, skin warm and intact •Pain 6/10 •No allergies •No medical/surgical hx •No meds •No other injuries How will you initially manage this injury?

Answer: Since the patient is stable and CMS is intact, you can implment RICE (rest-ice-compression-elevation) to the affect extremity while waiting for the HCP. Also, expect to administer pain medication and arrange for x-ray.

A patient with acute shortness of breath is admitted to the hospital. What is the best action for the nurse to take during the initial assessment of the patient? Delay assessment until pulmonary function tests have been completed. Complete the full admission assessment questionnaire and check for allergies. Ask specific questions about this episode of respiratory distress and conduct a focused respiratory assessment. Ask the patient to lie down to complete a full physical assessment.

Ask specific questions about this episode of respiratory distress and conduct a focused respiratory assessment.

A nurse is assessing a post-operative client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What action by the nurse is best? Assess the client for more specific signs of infection. Conclude that an infection is not present. Request that the provider order blood cultures. Document findings and continue to monitor.

Assess the client for more specific signs of infection.

Signs, Symptoms, or History Identify if the information in the left column is more consistent with asthma or COPD 1-Onset usually less than 40 yr 2-Long history of smoking 3-History of allergies 4-Dyspnea absent except during exacerbation 5-Clinical symptoms intermittent 6-Smoking not cause 7-Thick, tenacious sputum 8-Progressive worsening of disease course 9-Onset usually 40-50 yr 10-Infrequently associated with allergies 11-Dyspnea during exertion

Asthma(A) vs COPD(C) 1. A 2. C 3. A 4. A 5. A 6. A 7. C 8. C 9. C 10. C 11. C

An RN is working on the ventilator unit and is delegating tasks to the assistive personnel (AP). Which of the following tasks is appropriate to delegate to the AP and will assist in reducing the risk of pneumonia in patients on ventilators? (Select all that apply) A.Provide endotracheal with strict sterile technique. B.Provide routine oral care with chlorhexidine. C.Assess lung sounds every shift and as needed. D.Keep the HOB elevated between 30-45 degrees. E.Evaluate patient response to repositioning.

B, D B: provide routine oral care with chlorhexidine D: Keep the HOB elevated between 30-45 degrees.

The nurse is teaching pursed lip breathing to a patient with severe chronic obstructive pulmonary disease (COPD). The patient asks why is it helpful to breathe using this technique. What is the best response by the nurse? A. "It is easier on your lungs when you inhale." B. "It helps to remove carbon dioxide trapped in the lungs." C. "It helps to loosen secretions in the lungs." D. "It decreases oxygen so that you don't get oxygen toxicity."

B. "It helps to remove carbon dioxide trapped in the lungs."

A client is admitted to the hospital with anemia and dyspnea at rest. Which question is most appropriate for the nurse to ask when determining the extent of the client's activity intolerance? A. "Have you been able to keep up with all your usual activities? B. "What daily activities were you able to do 6 months ago compared with the present?" C. Are you more tired currently than you used to be? D. "How long have you been having difficulty breathing?"

B. "What daily activities were you able to do 6 months ago compared with the present?"

Your highest priority at this time is to ensure A. Fluid Status B. Adequate Oxygenation C. Adequate rest

B. Adequate Oxygenation Adequate oxygenation: Rationale: Airway and breathing are always priorities. ABC's Providing supplemental oxygen is essential for this patient.

Which client is at highest risk for a HAI (hospital acquired infection)? A.A 56 year old diabetic with nonadherence to medication plan. B.An 82 year old with heart failure requires a foley catheter for hourly output. C.A 68 year old with COPD receiving IV antibiotic therapy. D.A 26 year old with a fractured tibia and fibula requiring surgery.

B. An 82 year old with heart failure requires a foley catheter for hourly output. Indwelling foley catheters have a high incidence of causing HAIs

Post-op Day 3: Temp 101.5, malaise, increased pain What is the cause? A. Inflammation B. Infection-related inflammation c. Uncertain

B. Infection-related inflammation Rationale: Patients experience inflammation due to the tissue injury of surgery as seen on the last slide. However, we'd expect these manifestations would begin to slowly resolve as the days following surgery proceed. Although manifestations of inflammation in a surgical patient could continue mildly for several days to a couple weeks following the procedure, they should not significantly worsen several days after surgery as is seen on this slide with the temp of 101.5 and malaise. Therefore, it is likely this patient is experiencing infection.

Post-op Day 4: Purulent drainage on dressing, incision red and swollen. What is the cause? A. Inflammation B. Infection-related inflammation c. Uncertain

B. Infection-related inflammation Rationale: The purulent drainage indicates this patient is likely experiencing infection-caused inflammation.

During change of shift, the nurse is told a patient's laboratory results showed a shift to the left (increase in bands). Which assessment is the nurse most likely to perform upon assuming care of the patient? A. Check for signs and symptoms of an inflammatory response. B. Look for signs of infection and check temperature and pulse. C. Look for signs of bleeding, such as petechiae. D. Check for signs of anemia, such as pallor or tachycardia.

B. Look for signs of infection and check temperature and pulse.

A patient is dyspneic with a respiratory rate of 28 breaths per minute. What action should the nurse take first? A.Obtain Arterial Blood Gases B.Raise the HOB to 45 degrees or more C.Notify the health care provider D.Administer 100% oxygen

B. Raise the HOB to 45 degrees or more Easier to breathe when in a semi-to high fowlers position. The others need more assessment data. No information provided that would prompt those interventions.

A client returns to the medical unit after having an appendectomy. The RN is performing an assessment. The incision is slightly red, with mild swelling, intact, and no drainage. Temp is 99.6 F, Pulse is 82, and WBC count is 11,000. What is the most likely cause of the assessment findings? A. An infection is developing from the incision. B. The findings suggest an acute local inflammatory response. C. The patient is developing early signs of sepsis. D. The findings are suggestive of dehiscence.

B. The findings suggest an acute local inflammatory response.

What is a characteristic of chronic inflammation? A. It may last 2-3 weeks. B. The injurious agent persists or repeatedly injures tissue. C. Neutrophils are the predominant cell type at the site of inflammation. D. Symptoms manifest suddenly.

B. The injurious agent persists or repeatedly injures tissue. All other options describe acute inflammation

A nurse is assessing the condition of a patient with Cor pulmonale related to COPD. Which assessment finding does the nurse anticipate? A. decreased jugular vein distension (JVD) B. increasing peripheral edema C. capillary refill of less than three seconds D. Nausea, vomiting, and diarrhea

B. increasing peripheral edema

A hospitalized patient develops a severe infection after being admitted with a diagnosis of pneumonia. The patient's blood pressure is 92/54, heart rate 122, respiration 28, oxygen saturation 92% on 4L per nasal canula, and temperature 102.6 'F. Which order should the nurse implement first? A.Contact lab to draw CBC, Electrolytes, and lactate level. B.Administer a 1000 mL fluid bolus of Normal Saline. C.Collect blood and sputum cultures. D.Administer 2 grams of IV Vancomycin.

B.Administer a 1000 mL fluid bolus of Normal Saline.

A client with COPD is sitting in a high-fowler's position with oxygen at 2L per nasal cannula. The client develops increasing dyspnea. Which action should the RN take first? A.Call the healthcare provider. B.Obtain a pulse oximeter reading. C.Increase the oxygen amount. D.Check the client's blood pressure.

B.Obtain a pulse oximeter reading.

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? Dry mucous membranes Barrel-shaped chest Bilateral crackles in lungs Weak cough effort

Bilateral crackles in lungs

The nurse is evaluating teaching provided to a patient about ferrous sulfate. The nurse determines additional instruction is needed when the patient responds with which statement? A. "My stools may turn dark greenish black in color." B. "I can take the iron with food if it upsets my stomach." C. "I can take the iron and calcium supplements at the same time." D. "I will increase my fluid and fiber intake as long as I am on the iron."

C. "I can take the iron and calcium supplements at the same time."

A patient has sustained a severe right ankle sprain. Upon assessment the ankle is moderately swollen, painful, with limited range of motion and diffuse ecchymosis. Which type of inflammation is the patient experiencing? A. Chronic B. Subacute C. Acute D. Prolonged

C. Acute

The nurse assesses a patient who sustained a scalding burn to the left dorsal surface of the hands and fingers that occurred one day ago. There is redness, swelling, and warmth. The patient has pain, decreased fine motor movements, and limited range of motion. What do these findings indicate? A. A serious fourth degree burn. B. A serious infection that should be reported. C. Cardinal signs of inflammation. D. Probable inappropriate first-aid treatment.

C. Cardinal signs of inflammation.

Your post-op patient's CBC comes back with a WBC level of 18,000 cells/uL the morning after surgery. What will you do? A. Notify the charge nurse. B. Document in a progress note. C. Further assess the patient. D. Request an order for blood cultures.

C. Further assess the patient. Rationale: Assess your patient for additional and specific manifestations of infection (vitals, incision, sx of distress/pain/malaise, skin color/temp/moisture, mental status, lungs [could be developing post-op pneumonia], urine [could be developing UTI]). If all are negative, the elevated WBC count is likely due to the inflammation of surgery.....WBCs were activated and production was increased as part of the cellular response phase of the inflammatory process which was triggered with the tissue trauma of surgery.

An older resident living in a long-term care facility asks for help to go to the bathroom more frequently than usual. The nurse suspects a urinary tract infection. What changes in the immune system of an older adult should the nurse keep in mind? Select all that apply. A. Older adults are less likely to become septic because of built up antibody- antigen activity. B. Urinalysis results for older patients are more likely to show false negative results. C. Older adults may not have a fever during inflammatory or infectious episodes. D. Older adults tend to have a weakened or slower immune response.

C. Older adults may not have a fever during inflammatory or infectious episodes. D. Older adults tend to have a weakened or slower immune response.

As evidenced by A Lung sounds B Vital Signs C Sputum gram stain

C. Sputum gram stain Sputum gram stain: Rationale: this is the best evidence that our patients has pneumonia. Other conditions can cause abnormal lung sounds and vital sign changes.

The nurse has just administered a benzodiazepine medication to a pre-operative patient. What should the nurse do next? A. Document the administration. B. Call the operating room to report the medication has been given. C. Raise the side rails and place the call light in reach. D. Ask the family members if they have any questions.

C. raise the side rails and place the call light in reach. Ensure the safety of your patient who just received a sedating medication first, then address the other options.

The nurse has attended a staff education program about infection control guidelines. Which of the following statements by the nurse would indicate a correct understanding of the program "I will wear a particulate respirator mask (N95) when feeding a client with influenza." "I will wear a surgical mask when checking the pulse of a client with pulmonary tuberculosis (TB)." "I should wear a protective gown when entering the room of a client with meningococcal meningitis." "I should wear clean gloves when bathing a client with atopic dermatitis (eczema) who has draining lesions."

Correct answer = D: A."I should wear clean gloves when bathing a client with atopic dermatitis (eczema) who has draining lesions." A = droplet needed for influenza B = airborne (N95) needed for TB C = droplet needed for meningococcal meningitis

The nurse enters the hospital room of a patient admitted with pneumonia who has a known history of asthma. The patient is sitting at the side of the bed, leaning over the bedside table. Respirations are deep and rapid. Audible wheezing can be heard. What actions should the nurse take? A.Check the patient's blood pressure B.Ask the patient when this episode started and what may have triggered it C.Administer albuterol by metered dose inhaler per the patient's prn order D.Teach the patient about the need to use a reliever inhaler as soon as symptoms begin

C.Administer albuterol by metered dose inhaler per the patient's prn order •The patient is already sitting up in a position that supports ventilation. You have an order to administer a SABA prn; this should be provided as soon as possible. Further assessment, as well as evaluation of the patient's response will be needed from there. •Knowing the BP is not essential before taking action. •The assessment questions in option B can be deferred until the patient's respiratory status is stable. •A patient in respiratory distress will not be able to learn; teaching should be deferred until the patient's respiratory status is stable.

A client diagnosed with latent tuberculosis has completed two months of Isoniazid (INH) therapy returns to the clinic for follow up. The nurse notes that the client's skin has a yellowish discoloration. Which laboratory test does the nurse anticipate will be ordered? A.CBC B.Platelet count C.Liver function test D.Electrolytes

C.Liver function test

What does the mechanism of chemotaxis accomplish? A.Causes the transformation of monocytes into macrophages B.Involves a pathway of chemical processes resulting in cellular lysis C.Migration of neutrophils and monocytes to an area of injury D.Slows the blood flow in a damaged area, allowing migration of leukocytes into tissues.

C.Migration of neutrophils and monocytes to an area of injury

The nurse is providing discharge instructions for a client who was admitted with a COPD exacerbation related to pneumonia. The client reports not having an appetite, and is too tired to even eat at times. What should the nurse include in the discharge plan? A.Contact the local community meals on wheels program to assist the client with meals. B.Provide a sample three meal a day menu for the client to follow. C.Provide written examples of small portions high protein, high calorie foods/snacks that should be spaced out throughout the day. D.Encourage the client to eat high fat foods and vegetables.

C.Provide written examples of small portions high protein, high calorie foods/snacks that should be spaced out throughout the day.

Use the CDC's Coronavirus website to answer the following question: What information should the nurse include when teaching a patient about how Coronavirus (COVID-19) is transmitted? COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. The virus is thought to spread mainly through food handling. COVID-19 spreads to people through the water in lakes, oceans, rivers, or other natural bodies of water, COVID-19 frequently spreads through drinking water.

COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus.

The nurse caring for a client with sepsis writes the client problem of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? Reworded question: "What will help my patient with fever and chills feel more comfortable?" A.Ambulate the client in the hallway every shift. B.Monitor blood glucose, lactic acid, and creatinine levels. C.Apply sequential compression devices to the lower extremities. D.Administer acetaminophen 650 mg by mouth every four hours PRN.

Correct answer = D: Administer acetaminophen 650 mg by mouth every 4 hours PRN. Rationale: this will help decrease fever/chills, which is the cause (etiology) of the patient's alteration in comfort. The other interventions are either unrelated to the etiology of the problem or may make the patient more uncomfortable (walking).

Use the CDC's healthcare-associated infections website to answer the following question: Based on current evidence, what type of isolation precautions are recommended by the CDC for methicillin resistant Staphylococcus aureus (MRSA)-colonized or infected patients in acute care inpatient settings? Airborne precautions None beyond standard precautions Contact precautions Droplet precautions

Contact precautions

A client is admitted to the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? A.Start an IV with an 18-gauge catheter. B.Administer norepinephrine by intravenous infusion. C.Obtain arterial blood gases (ABGs). D.Insert an indwelling urinary catheter.

Correct answer = A: Start an IV with an 18-gauge catheter Rationale: The low BP and cold clammy skin indicate inadequate circulation. More fluid is needed in the vascular space. Prompt correction of this issue will require IV fluids. An IV will need to be established in order to do this. A large bore IV should be used, if possible, since it will allow fluids in infuse faster. The other interventions on the list are important, but obtaining IV access is the highest priority.

The nurse knows the short, high-pitched sounds heard during inspiration are most likely to indicate: A.Fluid is accumulating in the alveoli B.Excess mucous cannot be expectorated C.Bronchiole air passages have constricted D.Lung tissue has become fibrotic

Correct answer = C (Bronchiole air passages have constricted): the musical noise of wheezing is cause by air moving through narrowed passages Notes on other options: •Fluid is accumulating in the alveoli: we would expect to hear crackles or rales (snap, crackle, pop of milk on Rice Krispies) •Excess mucous cannot be expectorated: we would expect to hear course crackles or rhonchi (snoring sound of air moving over mucous) •Lung tissue has become fibrotic: we would expect course rales/crackles (sound of Velcro being pulled apart)

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? A.Vital signs: Temp of 100.4 F; HR of 102; RR of 20; BP of 102/60. B.A white blood cell count of 21,000/mcL. C.A urinary output of 50 mL in the last four hours. D.Client Glasgow score of 11 fours ago, now is 12. RULE OF THUMB: adequate urine output for an adult patient is 30 mL/hour (0.5mL/kg/hr for a 140-pound adult)

Correct answer = C: A urinary output of 50 mL in the last four hours Rationale: Options A, B would be expected in a patient diagnosed with septic shock. D. indicates minor improvement; while not normal, it is not a negative or significant change that would necessitate immediate intervention. As a general rule of thumb, adult urinary output should be at least 30 mL/hr (we can calculate more specific parameters based on weight). Option C indicates poor renal perfusion, which indicates worsening shock.

A client who is hospitalized for a hip replacement develops pneumonia three days after surgery. Which type of pneumonia has the client most likely developed? Community acquired pneumonia Hospital acquired pneumonia Opportunistic pneumonia Ventilatory associated pneumonia

Hospital acquired pneumonia

The nurse is caring for a patient who has septic shock. Which order should the nurse implement first? Antibiotics to treat the underlying infection. Vasopressors to increase blood pressure IV fluids to increase intravascular volume. Corticosteroids to reduce inflammation.

IV fluids to increase intravascular volume.

Polly's WBC count is 21,000/µL and blood cultures reveal gram-positive cocci. Over the course of the next day Polly becomes more confused. Her oxygen saturation falls to 85% despite receiving 100% oxygen via a nonrebreather mask. She is intubated and mechanically ventilated. A nasogastric tube is inserted, and continuous enteral feedings are begun. The health care provider determines the need to order IV methylprednisolone (Solu-Medrol). The patient's husband asks you how this drug will help his wife. Your best response is A."This drug may help increase Polly's respiratory rate." B."This drug may help increase Polly's blood sugar." C."This drug may help increase Polly's blood pressure." D."This drug may boost Polly's immune system."

Correct answer: C: "This drug may help increase Polly's blood pressure." Rationale: IV corticosteroids may be given to patients with septic shock who cannot maintain an adequate BP after receiving fluids and vasopressor therapy, such as norepinephrine and vasopressin.

Four days later, Donna has been switched from IV to oral antibiotics and is preparing for discharge. What statement by the patient would indicate a need for further teaching? A.I should continue to rest and drink fluids B.I will continue to cough, deep breathe, and use my incentive spirometer C.I will take my antibiotics as directed until all are gone D.Since I have had pneumonia, I no longer need to get the pneumonia or influenza vaccines

Correct answer: D: Since I have had pneumonia, I no longer need to get the pneumonia or influenza vaccines. What will you teach this patient: Teach the importance of rest and fluids while recovering, need to continue to cough and deep breath (C/DB), the importance of finishing the antibiotics, as well as food or drug interactions with the prescribed antibiotic, avoidance of alcohol and smoking, importance of staying up-to-date on immunizations

Which manifestation is NOT expected during an inflammatory response? Edema Heat Cyanosis Pain

Cyanosis

A patient is taking prednisone for acute inflammation related to a rheumatoid arthritis exacerbation. What instruction by the nurse is most important? A. "You have a higher risk of developing cancer." B. "Avoid eating with this medication." C. "Check over-the-counter meds for acetaminophen." D. "Do not stop the medication abruptly if you have side effects."

D. "Do not stop the medication abruptly if you have side effects."

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient states he no longer enjoys going out with his friends. What is the best response by the nurse? A. "There are a variety of support groups for people who have COPD." B. "You should ask your provider to prescribe you an antianxiety medication." C. "You should go with your friends. It will make you feel better." D. "Tell me more about what is causing you to limit social activities."

D. "Tell me more about what is causing you to limit social activities."

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? A. Monitor white blood cell counts. B. Check the skin for areas of redness. C. Measure the temperature every 2 hours. D. Ask about feelings of increased fatigue or malaise.

D. Ask about feelings of increased fatigue or malaise. This patient is taking corticosteroids which inhibit inflammation; therefore, the patient cannot initiate a normal, vigorous inflammatory response when tissues are injured for any reason, including infection. We are particularly concerned about how this will affect the patient's ability to fight infection, so be alert for more subtle manifestations of infection in any patient with a suppressed inflammatory response for any reason. Fatigue or malaise may be their only obvious manifestation.

The nurse should teach the client with asthma to avoid which precipitating factor of an acute asthma attack? A. Wearing an N-95 mask B. Performing the Valsalva maneuver C. Using a cotton pillowcase D. Exposure to cigarette smoke

D. Exposure to cigarette smoke

A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which assessment findings does the nurse interpret to be clinical indicators of sepsis? A. Decreased white blood count and increased hematocrit. B. Increased oxygen saturation and decreased clotting times. C. Decreased neutrophil count and decreased glucose level. D. Increased serum lactate level and rising neutrophil count.

D. Increased serum lactate level and rising neutrophil count.

The nurse is caring for a patient with sepsis. Which ordered intervention should the nurse perform first? A. Prepare the patient for a diagnostic CT scan. B. Draw a complete blood count (CBC). C. Administer an antipyretic. D. Infuse a 500 mL bolus of 0.9% sodium chloride solution.

D. Infuse a 500 mL bolus of 0.9% sodium chloride solution.

After assessing a patient with pneumonia, the nurse identifies ineffective airway clearance as a nursing problem that needs to be addressed. Which assessment finding is consistent with this problem? Weak, loose, nonproductive cough Respiratory rate of 28 breaths/minute Expectoration of large amounts of greenish sputum Resting pulse oximetry (SpO2) of 85%

Weak, loose, nonproductive cough

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse determines that the patient's nutrition status is impaired after noting a weight loss of 30 pounds. Which intervention would the nurse add to the plan of care? A. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet. B. Order fruits and fruit juices to be offered between meals. C. Encourage the patient to double carbohydrate consumption and decrease fat intake. D. Order a high-calorie, high-protein diet with six small meals a day.

D. Order a high-calorie, high-protein diet with six small meals a day.

A nurse reads a client's Mantoux skin test as positive and notes that the previous results were negative. The client becomes upset and asks the nurse what this means. The nurse's best response is based on the understanding that the client has which condition? A.No evidence of tuberculosis B.Systemic tuberculosis C.Pulmonary tuberculosis D.Exposure to tuberculosis

D.Exposure to tuberculosis

The nurse is caring for four clients with asthma. Which client does the nurse assess first? A.The client with a barrel chest and clubbed fingernails B.The client with an O2sat level of 92% at rest C.The client whose peak expiratory flow rate increases 12% post- nebulizer treatment D.The client whose heart rate is 140-160 beats/min

D.The client whose heart rate is 140-160 beats/min

An 82 year old female patient with an indwelling urinary catheter has new onset of confusion. What potential cause of this change should the nurse most suspect? ICU psychosis Medication allergy Fatigue Infection

Infection

•Explain why the patient is weak and does not tolerate activity but has a pulse oximetry reading of 95-97%.

Due to the lack of oxygen carrying capacity (low RBCs and hgb), all available hemoglobin binding sites on red blood cells will fill more easily (resulting in a high oxygen saturation).....yet there still is little oxygen making it to the tissues since there simply is not enough oxygen "carriers" (red blood cells) to get it there.

Which assessment findings would be most expected in a patient with anemia? Fatigue and pale skin A recent loss of consciousness Shortness of breath and low-grade fever Cough and confusion

Fatigue and pale skin

Use the CDC's healthcare-associated infections website to answer the following question: The nurse is providing discharge teaching to the caregiver of a patient with vancomycin-resistant enterococci (VRE). In order to reduce risk of transmission to the caregiver or others in the household, what information should the nurse include in the teaching? (Select all that apply.) Wear a mask when you are within three feet of your family member who has VRE. Frequently clean areas of the home that may become contaminated with VRE, such as bathrooms. Wash your hands with soap and water or use alcohol-based hand sanitizer before preparing food. Wear gloves if your hands may come in contact with body fluids that may contain VRE, such as stool.

Frequently clean areas of the home that may become contaminated with VRE, such as bathrooms. Wash your hands with soap and water or use alcohol-based hand sanitizer before preparing food. Wear gloves if your hands may come in contact with body fluids that may contain VRE, such as stool

Use the CDC's healthcare-associated infections website to answer the following question: Enterobacteriaceae are a large family of gram-negative bacteria that can produce enzymes called extended-spectrum beta-lactamases (ESBLs). ESBLs break down several antibiotics commonly used to treat infections, such as penicillins and cephalosporins, making them ineffective. How are these microorganisms most commonly spread in the United States? Through blood and body fluid exposure From one person to another through contaminated hands and surfaces By droplets generated from coughing Through airborne exposure among people in small rooms or spaces

From one person to another through contaminated hands and surfaces

Which manifestations are consistent with the compensatory stage of shock? Heart rate of 102 bpm, respiratory rate of 24 breaths per minute Absence of clinical manifestations Multiple organ failure Systolic blood pressure of 78 mmHg

Heart rate of 102 bpm, respiratory rate of 24 breaths per minute

Which manifestation is NOT expected in a patient with chronic obstructive pulmonary disease (COPD)? Use of accessory muscles to assist breathing Increased lateral diameter of the chest Decreased breath sounds Prolonged expiratory phase of respiration

Increased lateral diameter of the chest

Nursing action: Indicated/Contraindicated 1. Oxygen therapy 2. increase fluid intake to 4L/24 hours 3. Auscultate lung sounds every 24 hours 4. maintain fall precautions 5. allow frequent rest periods with activity as tolerated 6. Administer analgesics/antipyretics for significantly elevated temperature 7. ambulate patient the length of the long hallway 4x/day 8.closely monitor fluid balance

Indicated(I) Contraindicated(C) 1. I 2. C 3. I 4. I 5. I 6. I 7. C 8. I •Oxygen therapy as ordered; monitor pulse oximetry and s/sx of hypoxia. •Maintain adequate hydration while monitoring for potential exacerbation but 4L/24 hours is too much for this elderly patient with a history of heart failure. •Routine assessment of her lung sound should be done per protocol at a minimum. If indicated, the nurse should reassess more frequently. Encouraging fluids is easier if the fluids •Short trips to the bathroom and walking in the room as tolerated are appropriate, but long ambulation will not be tolerated until her condition improves. •Maintain fall precautions to prevent injury. •Individualize rest and activity to D.T.'s tolerance. •Administer analgesics prn to relieve the chest pain and antipyretics such as acetaminophen for significantly elevated temperature. May help if patient splints chest when coughing if in pain. •Monitor fluid balance for this patient (concern for both directions: deficit due to age and infection; excess due to chronic heart failure)

•One hour after receiving IV fluids and IV antibiotics, Polly's blood pressure continues to trend downward. A third fluid bolus of normal saline is administered with no hemodynamic improvement noted. •The ED physician orders the following: •Norepinephrine (Levophed) infusion to start at 8 mcg/min and titrated to a mean arterial pressure > than 65 mm Hg •Famotidine 20 mg IV now and every 12 hr •Regular insulin 10 units subcutaneously now

Key point: Think about why she is getting each of these meds: •Norepinephrine: to try to increase her BP because it is still low after receiving fluids; norepinephrine stimulates the sympathetic nervous system ("fight or flight") and will cause vasoconstriction, increased heart rate and contraction strength) •Famotidine (H2 receptor blocker will decrease gastric acid secretion): prevent stress ulcers •Insulin: blood glucose was 348 (patients have better outcomes if glucose is controlled)

A 56-year-old female is admitted to the emergency department with burns sustained when her gas furnace exploded as she was relighting a pilot light. She is alert & oriented x4 but very agitated and scared. She is having severe pain in her face and upper chest. She is shivering and complains of being cold, and her voice is raspy. Her hair and eyebrows are singed, and she has mixed areas of red, fluid-filled vesicles and waxy, white skin involving her face, anterior neck, entire right arm, left forearm, anterior chest and abdomen. HR is 132; RR is 36 breaths/min, BP per thigh is 110/52. Order the interventions below according to priority. A. Establish an IV access. B. Administer 100% humidified O2. C. Administer IV fluids. D. Estimate body surface area burned.

Order: 1.Administer 100% humidified O2. (intubate if needed) 2.Establish an IV access. 3.Estimate body surface area burned. Administer IV fluids.

Donna's chest x-ray reveals consolidation in her left lower lobe, consistent with pneumonia. Her WBC is 17,000/μL with an increased number of bands. Her electrolytes and BNP are within normal limits. Sputum gram stain shows gram-positive diplococci and many WBCs. Because of her age and altered mentation, the health care provider admits her to the hospital for treatment. On admission, Donna has bronchial breath sounds with dullness of the left lower lobe. Her O2 saturation is 87%. HR: 96. RR: 28. BP: 132/94 Temp 101.2F . What are the top three assessment findings that require immediate action by the nurse. BP 132/94 Pulse oximetry 87% HR 96 Temp 101.2F Dullness Left lover lobe RR 28 WBC 17,000/uL increased bands Altered mentation

Pulse Ox 87% RR 28 Altered Mentation O2 sat 87% on room is concerning; altered mentation is new onset and should be concerning as an early indicator for hypoxia; patient is tachypneic.

A patient is dyspneic with a respiratory rate of 28 breaths per minute. What action should the nurse take first? Raise the head of the bed to a 45 degree angle or higher Administer 100% oxygen per nasal cannula Request an order of an arterial blood gas level Notify the health care provider of the patient's status

Raise the head of the bed to a 45 degree angle or higher

Identify the acid-base imbalance: pH of 7.29 PaCO2 of 55 mmHg HCO3- of 25 mEq/L Metabolic Alkalosis, fully compensated Respiratory Acidosis, uncompensated Respiratory Alkalosis, partially compensated Metabolic Acidosis, partially compensated

Respiratory Acidosis, uncompensated

Mike's arterial blood gas results are: •pH 7.31 •PaO2 68 mm Hg •PaCO2 58 mm Hg •HCO3 32 mEq/L •SaO2 85% Interpret these results. A.Respiratory acidosis, no compensation B.Respiratory alkalosis, no compensation C.Respiratory acidosis, partial compensation D.Respiratory alkalosis, partial compensation

Respiratory acidosis with partial compensation (C): -pH is lower than the normal range (acidosis) -paCO2 is higher than the normal range (respiratory problem: "respiratory opposite" for ROME; pH and paCO2 levels have changed in the opposite direction with one higher than the normal range and one lower than the normal range) -HCO3 is higher than normal range (partial compensation: the renal system is trying to compensate)

Which assessment findings should the nurse recognize as early signs of sepsis? (select all that apply) Respiratory rate of 20 and Temp of 37 C WBC count of 15,000 and heart rate of 105 bpm Temp of 38.2 C and heart rate of 98 bpm Urine output of 23 mL/hr and mean arterial pressure of 60 mmHg

WBC count of 15,000 and heart rate of 105 bpm Temp of 38.2 C and heart rate of 98 bpm Urine output of 23 mL/hr and mean arterial pressure of 60 mmHg

The nurse is providing medication teaching to a patient who was prescribed an inhaled corticosteroid medication for asthma. Which statements are appropriate? Select all that apply. This medication often causes tachycardia, tremors, and anxiety. Rinse your mouth after using the inhaler to avoid oral candidiasis (thrush). Use good handwashing and avoid people who are sick since corticosteroids can increase risk of infection. Take this medication daily as prescribed to achieve its therapeutic effect.

Rinse your mouth after using the inhaler to avoid oral candidiasis (thrush). Use good handwashing and avoid people who are sick since corticosteroids can increase risk of infection. Take this medication daily as prescribed to achieve its therapeutic effect.

The nurse is caring for a patient with hepatitis B. Which isolation precaution category should be used? Standard/Universal Contact Airborne Droplet

Standard/Universal

The nurse is assigned to care for a patient in the emergency department with an asthma exacerbation. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, what would the nurse anticipate as the most likely next step in treatment? Systemic corticosteroids IV fluids Pulmonary function testing Biofeedback therapy

Systemic corticosteroids

Case Study Polly is a 58-year-old-female with a history of type 1 diabetes mellitus (since age 8), hyperlipidemia, renal insufficiency, and peripheral neuropathy. She was diagnosed with stage IV ovarian cancer 4 months ago. Surgical management at that time included a total hysterectomy, bilateral salpingo-oophorectomy, and lymph node biopsies. Two weeks after surgery, aggressive combination chemotherapy was started. Polly's husband brings her to the emergency department (ED) with shaking chills and fever. Her last chemotherapy was 2 weeks ago. He states she is very weak and barely able to hold her head up.

Unfolding case...look at following cards

Which of the following can be delegated to the CNA? 1.Obtain hourly vital signs, including hourly urinary output. 2.Assess intake and output. 3.Titrate norepinephrine infusion rates based on systolic BP. 4.Provide oral care at least q4hr. 5.Auscultate lung sounds at least q4hr. 6.Assess patient's level of consciousness hourly. 7.Give insulin per sliding scale to achieve blood glucose of <180 mg/dL. 8.Explain the reason for the various interventions. 9.Help position the patient to maximize comfort.

Tasks you can delegate: •Obtain hourly vital signs, including hourly urinary output. •Provide oral care at least q4hr. •Help position the patient to maximize comfort. Reasons you should not delegate the other tasks: •Assess intake and output. (can not delegate "assessment".....could delegate collection of I/O but this option specifies "assess" which means you are doing some clinical analysis about what those numbers mean). •Titrate norepinephrine infusion rates based on systolic BP. (nurse-level intervention) •Auscultate lung sounds at least q4hr. (nurse-level assessment) •Assess patient's level of consciousness hourly. (do not delegate "assessment" as noted above) •Give insulin per sliding scale to achieve blood glucose of <180 mg/dL. (nurse-level intervention) •Explain the reason for the various interventions. ("Explain" implies "teach", an intervention we cannot delegate).

Reflection Question: A patient with schizophrenia is taking the antipsychotic clozapine (Clozaril). The patient requires monthly absoolute neutrophil count (ANC) level monitoring. Today's lab report states WBC total is 6000/uL with 50 % neutrophils. What is the ANC? Why would we be concerned about a low ANC?

This is an example of a medication that can cause neutropenia. Currently 3000 cells/mcL (this is within the normal range for neutrophils) If the ANC is too low, it would compromise our patient's ability to initiate the inflammatory response in the event of cell/tissue injury. This is particularly concerning if the cells/tissues are being injured by a pathogen/infection as the patient would have reduced ability to fight the infection. General categories of neutropenia (low neutrophil level): •<1500 cells/mcL = mild neutropenia •<1000 cells/mcL = moderate neutropenia •<500 cells/mcL = severe neutropenia We need to be extra vigilant with infection control and monitoring for manifestations of infection when caring for a neutropenic patient. Even subtle manifestations of infection (such as a temp of just 100.4) are cause for concern and should be communicated to the provider.

Mike is a 65-year-old male who is being admitted from the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD). Mike has been using ipratropium (Atrovent) and albuterol (Proventil) metered-dose inhaler for control of his symptoms. His admission vital signs are as follows: blood pressure 158/86 mm Hg, heart rate 118 beat/min, respiratory rate 36 breaths/min, temperature 101.4° F (38.4° C), and SaO2 85%. He is 5 ft 10 in tall, weighs 180 lb, and has a marked barrel chest. Admitting Orders A.Sputum culture and sensitivity B.IV of D5W/0.45 NS at 50 ml/hr C.Cefuroxime axetil (Ceftin) 1 g q8hr IVPB D.Ipratropium and albuterol (DuoNeb) nebulization QID E.O2 at 2 L/nasal cannula F.CBC, ABGs, and electrolytes G.Chest x-ray H.Prednisone 40 mg PO bid I.Up with assistance •What interventions would you implement immediately? (select all that apply) •What may you want to clarify with the provider?

Thoughts on first question: ABCDEH - these interventions target the pathology of what is taking place (COPD with exacerbation most likely from a respiratory infection) and will help improve the patient's condition. The question doesn't specify the need to identify order, but starting oxygen should be done first. Thoughts on second question: consider calling the provider regarding the following: •Does the provider want to order blood cultures (look at the temp; we know one of the most common causes of a COPD exacerbation is a respiratory infection; we should see if the provider may want blood cultures, too, before starting the antibiotic) •Diet order? •Does the provider want a PRN neb order (such as albuterol) in the event the patient becomes short of breath between the ordered Duoneb treatments •Does the provider want to order any oxygen parameters (e.g., increase O2 to maintain sats of 90% - 92%; we expect a bit lower sats in patients with COPD, but patients still need to be adequately oxygenated)

What can you do to prevent infection in this patient? 78-year-old patient, status post hemicolectomy this morning. IV of LR at 75 mL/hr. Indwelling urinary catheter draining clear yellow urine. Abdominal incision covered with dressing.

What are his risk factors? ·Portals for entry: oIncision oIV oUrinary catheter ·Hospitalized (increased virulence of microbes) ·Pain (increased stress hormone release = decreased immune/inflammatory response; decreased movement) ·Age (decreased immune system function; decreased circulation) ·Decreased mobility (decreased lung expansion; decreased circulation) ·Sedation from meds (less movement; less lung expansion) What interventions can you implement? ·Handwashing ·Aseptic technique for incision care ·Aseptic IV care ·Catheter/peri-care ·Remove catheter as soon as able ·Pain control ·Early ambulation ·Cough/deep breathe (C/DB)

Select four priority orders you will implement first. Orders: A.O2 at 4L per NC; titrate to keep sats at 92% or above B.VS Q 4 hours C.IV of 0.9% NS at 75 mL/hr D.Levofloxacin 750 mg IV once daily E.Blood cultures x 2, Sputum culture/sensitivity F.Duoneb QID G.Up with assist H.Regular diet

What will you do first? A, C, E, D Other notes: •Assist pt to a position to support respiratory effort (upright/high fowlers, if able) and apply oxygen and •Be sure to evaluate response to oxygen therapy 10 - 15 minutes later. Document when you started the oxygen. Document the patient's response. From there, consider your patient's status and resources available to you: •Can someone else initiate the lab orders? If so, start the IV and fluids, so you are ready to start the antibiotic as soon as the blood cultures are drawn and sputum specimen is collected (do not delay starting the antibiotics if the patient cannot produce a sputum specimen). •How long has it been since vitals were last collected? Make sure they are collected every 4 hours and whenever a status change is occurring/suspected •Is the patient experiencing respiratory distress? If so, start the Duoneb as soon as possible. •What time is it and when did the patient last eat? •Remember that - in the midst of this - you need to complete the admission assessment

A patient with right lower-lobe bacterial pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? White blood cell count has changed from 17,000/µL to 9,000/µL. A pleural friction rub is heard in the right lung base. Increased tactile fremitus is palpable over the right chest. The patient coughs up small amounts of green mucus.

White blood cell count has changed from 17,000/µL to 9,000/µL.

Oxygen carrying capacity What would cause a problem? How would you identify a problem if it occurred? (recognize cues)

anemia; low hemoglobin; blood loss/red blood cell loss manifestations of anemia such as shortness of breath with activity (or at rest if severe); pale; fatigued; chest pain (if severe)

Peripheral perfusion What would cause a problem? How would you identify a problem if it occurred? (recognize cues)

atherosclerosis; hypertension; vasoconstriction; poor CO; arterial thrombi; arterial compression weak pulses; cool, pale extremities; prolonged cap refill; signs of organ dysfunction if they are not getting enough oxygen

Cardiac Output What would cause a problem? How would you identify a problem if it occurred? (recognize cues)

cardiomyopathy; HF, valve problems; hypertension; low fluid volume low blood pressure; weak pulses; cool, pale extremities; prolonged cap refill; confusion; poor urine output

The nurse is assessing a client with active tuberculosis disease (TB) for early manifestations of inadequate oxygenation (hypoxia). Which manifestation would NOT be an early indication of hypoxia? cyanosis change in mental status tachypnea restlessness

cyanosis

Which assessment finding would be of most concern to the nurse caring for a patient with sepsis? hyperactive bowel sounds increased urine output increased lethargy intermittent coughing

increased lethargy

David Montanari is a 19-year-old male who suffered a T4-T5 burst fracture as a result of a motorcycle accident on Sunday. He underwent spinal fusion on Sunday evening and has had an uneventful recovery period. David has no sensation or movement below the nipple line and is bed bound. Three day later, he is frustrated, hopeless, guilty, and anxious about his condition and is refusing postoperative interventions, including pain medication and use of the incentive spirometer. He has an order for 0.5mg hydromorphone every 2 hours IV prn pain. •T = 100.6 F (38.1 C) Bowel sounds: Present •Skin: Intact and free of redness Heart sounds: S1 S2 regular •Pulses: 2+ Pain: 7/10 •Skin: intact and free from redness •BP = 118/64 •P = 70 RR = 18, shallow O2 Sat = 93% (2 L/min via nasal cannula) •Lungs: Diminished with crackles bilaterally in the bases at the end of inspiration What assessment data is of most concern for you and David right now?

no sensation or movement below the nipple line and bed bound frustrated, hopeless, guilty, anxious refusing medication and incentive spirometer T= 100.6 F Pain: 7/10 RR/lungs: shallow breaths, O2 Sat = 93% (2 L/min via nasal cannula), Diminished with crackles bilaterally in the bases at the end of inspiration

T = 100.6 F (38.1 C) Bowel sounds: Present Skin: Intact and free of redness Heart sounds: S1 S2 regular Pulses: 2+ Pulses 2+ Pain: 7/10 Skin: intact and free from redness BP = 118/64 P = 70 RR = 18, shallow O2 Sat = 93% (2 L/min via nasal cannula) David Montanari is a 19-year-old male who suffered a T4-T5 burst fracture as a result of a motorcycle accident on Sunday. He underwent spinal fusion on Sunday evening and has had an uneventful recovery period. David has no sensation or movement below the nipple line and is bed bound. Three day later, he is frustrated, hopeless, guilty, and anxious about his condition and is refusing postoperative interventions, including pain medication and use of the incentive spirometer. He has an order for 0.5mg hydromorphone every 2 hours IV prn pain. David is most at risk for ______ (self-injury, pneumonia, falls) as evidenced by_______(atelectasis, hopelessness, impaired mobility).

pneumonia atelectasis

Patient 1 has aspirated an object that is obstructing the right mainstem bronchus. A V/Q scan is done. How would you expect the results to look relative to baseline? A.Ventilation will be increased relative to perfusion B.Normal C.Ventilation will be decreased relative to perfusion

•Patient 1 answer = C. ventilation will be decreased relative to perfusion. This patient has a ventilation problem, so the ventilation measure will be lower than "normal." In other words, ventilation will be decreased relative to perfusion.

Patient 2 has a large pulmonary embolus. A V/Q scan is done. How would you expect the results to look relative to baseline? A.Ventilation will be increased relative to perfusion B.Normal C.Ventilation will be decreased relative to perfusion

•Patient 2 answer = A. ventilation will be increased relative to perfusion. This patient has a perfusion (blood flow) problem. Ventilation will be "normal" (even increased since the patient may start to hyperventilate). Blood flow around the lungs (perfusion) is lower than normal (the blood clot is causing this decrease).