NURS 309 Quiz 7 (Chap 28, 29, 32) RESP 1

Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration? 1. Warfarin (coumadin) 1.0 mg PO 2. Morphine sulfate 2-4 mg IV 3. Cephalaxin (Keflex) 250 mg PO 4. Heparin infusion at 900 units/hr

1 because 1.0 can be interpreted as 10 = overdose of med

The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? 1. Humidify patient's oxygen. 2. Use simple face mask instead of a nasal cannula 3. Provide pt with an extra pillow 4. Have pt sit up in a chair at the bedside

1 because when flow rate is higher than 4 L/min, mucous membranes can be dried out

As part of discharge teaching, nurse recommends that Mrs. B implement several important preventative measures at home. Which interventions are recommended by nurse? (select all) A. use soft-bristled toothbrush and avoid flossing B. shave with electric razor instead of blade razor C. inspect legs and feet daily D. run dehumidifier day and night E. continue warfarin (coumadin) prior to any invasive procedures F. briskly massage any red, tender areas in calf

A, B, C

What additional steps can the nurse take to relieve Mrs. Bs feelings of anxiety prior to discharge? (select all) A. encourage her to find local support group or coumadin clinic in her area B. provide websites or other resources where client can get helpful info C. Give Mrs. B the nurse's personal cell phone number so she can call or text anytime D. recommend she have a friend or relative check on her each day E. continue use of oral contraceptives

A, B, D

Mrs. B should also be instructed to avoid which OTC products? (select all) A. antihistamines B. aspirin, salicylates, ibuprofen, naproxen C. calcium carbonate (TUMS) D. acetaminophen (tylenol) E. antidiarrheal agents

B, D

Which actions should be implemented during administration of low molecular weight hep? (select all) A. massage site after injection to promote injection B. use subcutaneous sites at abdomen C. apply pressure over site after injection to prevent bleeding D. rotate injection sites E. aspirate for blood before injected medication

B, D

Which nursing interventions will reduce pain related to decreased venous flow? (select all that apply) A. apply cold packs B. elevate affected leg C. gently massage affected leg D. administer NSAIDS PRN for pain E. apply warm compress

B, E

What is the legal concern involved in this situation? A. assault B. fraud C. defamation D. malpractice

D.

Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT? A. measure calf circumference bilaterally B. observe for excessive bruising 3. Perform test for Homan's sign 4. auscultate for bruits

A. measure calf circumference bilaterally - provides data regarding affected leg and provides baseline for future

Less common complication of hep therapy is hep induced thrombocytopenia (HIT). after hep drip is discontinued and APTT is prescribed, what is the most important order the nurse would expect? A. platelet count B. WBC count C. renal function tests D. monitor client's intake and output

A. platelet count

To which nursing diagnosis should the nurse give the highest priority when planning care for Mrs. B? A. pain related to decreased venous flow B. risk for injury (bleeding) related to anticoag. therapy C. impaired physical mobility related to prescribed bedrest D. knowledge deficit related to lack of discharge teaching

B

Oncoming nurse is told to decrease hep infusion to 30 mL/hr. She walks into Mrs. B's room and IV is infusing at 50 mL/hr and Mrs. B. has observable hematuria in her urinary cath. Which action should nurse initiate first? A. obtain STAT APTT B. Stop hep infusion C. Assess vitals D. Observe surgical site for bleeding

B. stop hep infusion

Which food should the nurse instruct Mrs. B to avoid? A. apple products B. red meats C. green leafy vegetables D. nuts

C

At what rate should the IV pump be set to deliver the prescribed rate of infusion? (round to nearest whole number)

HCP prescribed 22 units per kg per hour so... 85x22 = 1,870 units/hr EASIEST WAY TO FIGURE OUT: (desired units per hour) x (mL of bag) / (amount of heparin in IV bag) 1870 x 500 / 25,000 = 37.4 = 37

A pt with a pulmonary embolus is receiving anticoagulation therapy with IV heparin. What instructions would you give the UAP who will help the pt with ADL's? 1. Use a lift sheet when moving and positioning the pt in bed 2. Use an electric razor when shaving the pt each day 3. Use a soft-bristled toothbrush or tooth sponge for oral care 4. Use a rectal thermometer to obtain a more accurate body temp 5. Be sure pt's footwear has a firm sole when the pt ambulates

1, 2, 3, 5 because it is important to avoid trauma to rectal tissue while on coagulant therapy because it could cause bleeding

A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume? 1. Exhaled after there is normal inspiration 2. Exhaled forcibly after a regular expiration 3. Inspired forcibly above a typical inspiration 4. Trapped in the alveoli after a maximum expiration

1. TV is amount of air exhaled after normal inspiration

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions? 1. Tidal volume 2. vital capacity 3. expiratory reserve 4. inspiratory reserve

1. TV is amount of air inhaled and exhaled while breathing normally

You are admitting a pt for whom a diagnosis pulmonary embolus must be ruled out. The pt's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The pt was recently in a motor vehicle crash 2. The pt participated in an aerobic exercise program for 6 months 3. The pt gave birth to her youngest child 1 year ago 4. The pt was on bedrest for 6 hours after a diagnostic procedure

1. because pt who have recently experienced trauma are at risk for DVT and PE

A nurse is caring for a group of clients on a med-surg unit. Which client has the highest risk for developing a pulmonary embolism? 1. Obese client with leg trauma 2. Pregnant client with acute asthma 3. Client with diabetes who has cholecystitis 4. Client with pneumonia who is immunodeficient

1. client has 2 risk factors for development of PE: obesity and trauma

A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction? 1. Blowing vigorously into the mouthpiece 2. Getting into a chair to use the spirometer 3. Coughing deeply after using the spirometer 4. Using lips to form a seal around the mouthpiece.

1. client should exhale before inhaling slowly and deeply through the spirometer to maximize lung expansion

A nurse is caring for a variety of clients. For which client is it MOST essential for the nurse to implement measures to prevent pulmonary embolism? 1. 59-year-old who had a knee replacement 2. 60-year-old who has bacterial pneumonia 3. 68 yr old who had emergency dental surgery 4. 76 yr old who has a history of thrombocytopenia

1. clients who have had joint replacement have decreased mobility, at risk for thrombophlebitis that might lead to PE if clot becomes dislodged into circulation

Levofloxacin (Levaquin) 750 mg IVPB is prescribed for a client with pneumonia. The dose available is 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per min should the nurse regulate the IVPB to infuse? Round to nearest whole number.

150mL/90min x 15dropspermL = 25 gtt/min

You are supervising an RN who floated from the med-surg unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply) 1. Position pt in supine and turned on his side 2. Apply direct lateral pressure to the nose for 5 minutes 3. Maintain standard body substance precautions 4.Apply ice or cool compresses to the nose 5. Instruct pt not to blow the nose for several hours

2, 3, 4, 5 because correct position is upright and leaning forward to prevent blood from entering stomach and avoid aspiration; all other actions are appropriate

A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the MOST from receiving oxygen via a nasal cannula? 1. Has an upper respiratory infection 2. Receives many visitors while sitting in a chair 3. Has a nasogastric tube for gastric decompression 4. Exhibits dry oral mucous membranes from mouth breathing

2. client is more mobile and will benefit from a less restrictive form of O2 administration. client will be able to talk w/o impediment of mask

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? 1. Tidal 2. Residual 3. Vital Capacity 4. Inspiratory reserve

2. residual volume is the amount of air remaining in the lungs after maximum exhalation

A nurse identifies that a client's hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin? 1. pH 2. Po2 3. Pco2 4. HCO3

3. The lower the Po2 and higher the Pco2 the more rapidly O2 dissociates from the oxyhemoglobin molecule.

After a surgery a client develops a DVT and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg IV every 12 hours is prescribed. The client has one IV site: a peripheral line in the left forearm. What action should the nurse take? 1. Stop heparin, flush the line, and administer the vancomycin. 2. Use a piggyback setup to administer vancomycin into the heparin. 3. Start another IV line for vancomycin and continue the heparin as prescribed 4. hold the vancomycin and tell the health care provider that the drug is incompatible w/ heparin

3. drugs are incompatible in same IV and must be administered separately; by instituting a second line for antibiotic, heparin can continue to infuse

Which term should the nurse use to most accurately report that Mrs. B may have developed a clot in her vein that is causing the pain and swelling in her leg? 1. Phlebitis 2. thrombosis 3. thrombitis 4. thrombophlebitis

4. Thrombophlebitis

Which intervention for a pt with a pulmonary embolus could be delegated to the LPN/LVN on your pt care team? 1. Evaluating the pt's report of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. because an LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation, under supervision of RN

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1. slow, deep respirations 2. normal oral temp 3. dry, unproductive cough 4. diminished breath sounds

4. because atelectasis involves collapsing of alveoli distal to bronchioles, breath sounds are diminished in lower lobes

A nurse is caring for a client in respiratory distress. The health care provider orders oxygen via a nonrebreather mask. Which mask should the nurse obtain to implement the oxygen order? 1 2 3 4 (all are pictures on pg 777 in mosby's)

4. nonrebreather mask can accurately deliver high concentrations of oxygen (>90%). cannot be used with a high degree of humidity 1 is a face mask, delivers low to medium concentrations of O2 (40-60%) flow rate 6-12 L/min 2 is Venturi mask, delivers precise high-flow rates of O2 3 is a face tent, delivers imprecise amount of O2

A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Check peak and trough levels of the antibiotic 2. Insert IV catheter to establish venous access. 3. Collect a sputum sample for culture and sensitivity 4. Administer prescribed antibiotic IV piggyback. 5. Obtain data about the client's history and physical status.

5, 2, 3, 4, 1

HCP prescribes: - administer IV bolus dose of hep 80 units per kg of body weight. - initiate IV infusion of 500 mL of D5W with 25,000 units of hep at a rate of 22 units of hep per kg of body weight per hour Hep bolus is available in 1,000 unit/mL concentration. Mrs. B weighs 187 lbs (85 kg). what is correct IV bolus dose of hep that nurse should administer?

85x80 = 6,800 units 6,800/1,000 x 1 mL = 6.8 mL ANSWER IS: 6.8 mL

Complication occurs later: Mrs. B is breathing rapidly, scared, nervous; Vitals - T 98, P 118 BPM, RR 36, BP 122/56; weak pulse, RR are shallow and labored, nailbeds cyanotic; chest pain nurse suspects PE Which action should nurse implement first? A. administer O2 B. stop hep infusion C. perform oral-pharyngeal suctioning D. Position client on right side

A

Prep for discharge: Calf circumference is equal bilaterally; Prothrombin is 12, INR is twice normal; O2sats per oximeter is 98% Based on findings, which action should the nurse implement? A. continue with discharge teaching B. Place Mrs. B on O2 C. Instruct Mrs. B to remain on bedrest D. Hold all meds and contact HCP

A

What should the nurse tell Mrs. B to avoid while on warfarin (coumadin)? A. alcohol B. television C. coffee D. soda

A

Which action can be delegated to the UAP who is assigned to the nurse caring for Mrs. B? A. obtain stool specimen for guaiac B. assess skin for bruising C. teach client to use soft toothbrush D. review side effects of anticoag.

A

What other steps can nurse take to reduce postop. risk of embolization formation? (Select all) A. provide adequate hydration B. increase use of sedation C. use elastic stockings or sequentials when indicated D. mobilize and ambulate client as early as possible E. perform routine administration of weight-based hep IV or give low molecular weight hep when indicated

A, C, D, E

If pharmacologic therapy is initiated, which lab value would indicate to the nurse that the heparinization has been reached? A. hemoglobin 9 g/dL B. APTT 65 seconds, control 35 seconds C. INR 1 D. Platelet count 250,000/mm3

B. APTT 65 seconds, control 35 seconds --- reflects desired therapeutic effect of heparin therapy

After consulting with HCP, nurse is to administer a hep antagonist. Which med will be administered? A. Vit K B. Protamine sulfate C. Enoxaparin (Lovenox) D. Ticlopidine (Ticlid)

B. protamine sulfate

At end of shift, nurse realizes the UAP has not reported obtaining stool specimen. Which communication is best for nurse to use with UAP? A. why didnt you obtain the stool specimen as you were assigned? B. you didn't complete your assignment with Mrs. B today C. I've noticed that Mrs. B's stool specimen was not obtained D. I'll go get that stool specimen from Mrs. B for you

C

Charge nurse learns of med error by night nurse, have to fill out error report, night nurse is unsure about the purpose of the report. Which description best identifies the purpose of an adverse occurrence (incident) report? A. documentation that protects nurse from potential lawsuit by client B. legal component of Mrs. B's med record C. hospital record that helps track patterns of risk to guide corrective action D. written report to attending HCP describing the occurrence

C

Nurse obtains O2sats, places Mrs. B on telemetry monitor, considers morphine. Which decision is most appropriate for nurse to make regarding the administration of low dose morphine at this time? A. dose should not be give since morphine can cause resp. depression B. dose should not be given because morphine causes side effects like constipation C. dose should be given because morphine reduces pain and anxiety D. dose should be given because morphine will sedate the client

C

During hep therapy, Mrs. B APTT was monitored every 6 hours. Midnight results were APTT 120 seconds, control 35 seconds. What action should nurse expect to initiate? A. increase rate of infusion B. continue rate of infusion C. decrease rate of infusion D. recalculate infusion rate

C. decrease rate of infusion

Mrs. B says she doesn't want to go home because she is afraid she will have another blood clot and kids need her, but husband is always gone. What is the best response by the nurse? A. the filter procedure will prevent blood clots from going to your lungs B. you need to talk to your husband about staying home and helping you out more C. I believe that God never gives us more than we can handle D. You seem to be feeling pretty overwhelmed right now.

D

Which nursing intervention should the nurse implement to help reduce risk for abnormal bleeding during hep therapy? A. monitor for dysuria or diarrhea B. auscultate breath sounds regularly C. ensure that vit k is readily available D. maintain hep on a continuous infusion pump

D

If outcome of test revels Mrs. B does have DVT, the nurse anticipates initiation of heparin therapy. Which route of administration should nurse anticipate for this treatment? A. oral B. subcutaneous C. IM D. IV

D. IV - frequently using a bolus dose of heparin followed by continuous IV infusion

Which of Mrs. B's meds places her at increased risk for development of DVT? A. antibiotics B. analgesics C. antiasthmatics D. oral contraceptives

D. oral contraceptives