Quiz 1
Nursing management of the patient having an allergic or anaphylactic reaction.
-Assess airway, breathing pattern, & vital signs -Observe for increasing edema & respiratory distress -Call RRT & provider for rapid initiation of emergency measures
Patient teaching regarding safe administration of the medication Warfarin. (dietary restrictions)
-Avoid alcohol, food fads, crash diets, & marked changes in eating habits
Management of the patient receiving peritoneal dialysis. - S/SX of peritonitis
-Cloudy dialysate drainage (first sign) -Diffuse abdominal pain -Rebound tenderness -Hypotension & other signs of shock
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowlers or supine position. D) Increase activity.
A
A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching? A)Lie supine to facilitate air entry B)Avoid pursed lip breathing C)Use diaphragmatic breathing D)Use chest breathing
C) Use diaphragmatic breathing Inspiratory muscle training and breathing retraining may help improve breathing patterns in patients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.
Patient teaching for the patient with a diagnosis of asthma. (home environment)
Common causative agents that may trigger an asthma attack are: dust, dust mites, pets, soap, certain foods, stress, & pollens.
Concepts related to safe administration of a beta-adrenergic blocking medication. (something to check)
Vital signs (especially BP) must be monitored at least every 15 minutes
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A) The patient experiences chest pain, palpitations, or dyspnea. B) The patient experiences a noticeable increase in heart rate during activity. C) The patients oxygen saturation level drops below 96%. D) The patients respiratory rate exceeds 30 breaths/min.
Ans: A Feedback: Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
A patient is receiving the first two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the patient in high Fowler's. B) Discontinue the transfusion. C) Auscultate the patient's lungs. D) Obtain a blood specimen from the patient.
Ans: B
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.
Ans: B
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.
Ans: B
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the patient's concerns? A) "All the donated blood in the United States is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility." C) "HIV was eradicated from the US blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low."
Ans: D
Management of the patient who is experiencing angina. - Assessment
-A 12-lead ECG which may show changes indicative of ischemia (T-wave inversion, ST elevation, or an abnormal Q wave) -Lab studies (cardiac biomarker testing) -Exercise or stress test -Cardiac catheterization, coronary angiography
Management of the patient who is experiencing angina. - Nitroglycerin (patient education)
-Carry med at all times as a precaution -Can be inactivated by heat, moisture, air, light, & time: needs to be renewed every 6 months -Should be taken prior to activity that may produce pain -If pain persists after taking 3 tablets at 5 minute intervals, call emergency services -Side effects: flushing, throbbing, headache, hypotension, tachycardia -Sit down while taking to avoid hypotension & syncope
Clinical manifestations of a patient experiencing disseminated intravascular coagulation (DIC).
-DIC is not an actual disease but a sign of an underlying condition -Bleeding from mucous membranes -Multi-organ dysfunction -AKI -Thrombosis -Decreased platelet count
Management of care for the patient receiving hemodialysis. (diet)
-Decrease protein intake -Decrease sodium intake -Restrict fluid
Caring for the patient experiencing respiratory acidosis. (treatment)
-Directed at improving ventilation -Bronchodilators: reduce bronchial spasm -Antibiotics: respiratory infections -Thrombolytics/anticoagulants: pulmonary emboli -Adequate hydration -Supplemental oxygen (with caution) -Mechanical ventilation
Safe administration of a packed red blood cell transfusion.
-Double-check labels with another RN/MD to confirm Rh type & ABO group -Initiate transfusion within 30 mins of removal from refrigerator -Run no faster than 5 mL/min for the first 15 mins -Monitor vitals & for signs of adverse reactions -Stop transfusion immediately if any adverse reactions occur & contact PCP -Administration should never exceed 4 hours -Change blood tubing after every 2 units transfused
Management of the patient receiving peritoneal dialysis. - Dietary alterations
-Encourage increased intake of protein & potassium -May need to limit carbohydrate intake
Management of the patient receiving peritoneal dialysis. - Nursing considerations for connections/disconnections
-Hand hygiene -Masks must be worn by anyone within 6 ft of the area
Management of the patient receiving peritoneal dialysis. - Long-term complications
-Hypertriglyceridemia -Abdominal hernias
Management of the patient experiencing diabetic ketoacidosis (DKA) (key treatments)
-Maintain & monitor fluid balance
Management of the patient with Addison's disease. (nursing management)
-Monitor BP/HR as patient moves from a lying, sitting, & standing position to assess for inadequate fluid volume; assess the skin color & turgor, change in weight, muscle weakness, & fatigue -Immediate treatment with IV fluids, glucose, & electrolytes (especially sodium); replacement of missing hormones; & vasopressors -Encourage patient to consume foods/fluids to assist in restoring fluid & electrolyte balance; educate patient on hormone replacement & administration of corticosteroids/mineralocorticoids -Minimize unnecessary activity/stress
Management of the patient who is experiencing angina. - Meds
-Nitrates [short/long-term reduction of myocardial oxygen consumption through selective vasodilation]: Nitroglycerin -Beta-blockers [reduction of myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart]: Metoprolol (Lospressor), Atenolol (Tenormin) -CCBs [slow HR and decrease strength of myocardial contraction]: Amlodipine (Norvasc), Diltiazem (Cardizem, Tiazac) -Antiplatelets [prevent platelet aggregation]: Aspirin, Clopidogrel (Plavix), Prasugrel (Effient) -Anticoagulants [prevent thrombus formation]: Heparin, Enoxaparin (Lovenox), Dalteparin (Fragmin) -Oxygen: 2 L/min NC
Management of the patient experiencing an acute myocardial infarction. (treatment)
-Obtain 12-lead ECG - Obtain lab specimens (cardiac biomarkers: troponin, creatine kinase, myoglobin) -Administer meds -Evaluate for indications of reperfusion therapy -Continue therapy as needed
Management of the patient who is experiencing angina. - Nitroglycerin (routes of administration)
-Oral preparations & topical agents: provide sustained effects -IV: hospitalized patient with recurrent ischemia or after revascularization procedures -Sublingual tablet or spray: given PRN for relief within about 3 minutes
Management of the patient receiving peritoneal dialysis. - Acute complications (complications - normal vs abnormal)
-Peritonitis -Leakage -Bleeding
Planning care for the patient with an exacerbation of COPD.
-Primary causes of an acute exacerbation are tracheobronchial infection & air pollution -Diaphragmatic breathing decreases RR, increases alveolar ventilation, & can help expel as much air as possible during expiration
Characteristics of ventricular tachycardia.
-Rate: 100 to 200 bpm (ventricular) & atrial depends on underlying rhythm -Rhythm: usually irregular, atrial can be regular -QRS: bizarre & abnormal shape, 0.12 seconds or more -P wave: very difficult to detect (atrial rate may be undeterminable) -PR interval: very irregular (if P waves are seen) -P:QRS ratio: difficult to determine, usually more QRS if P waves are present
Characteristics of atrial fibrillation.
-Rate: 300 to 600 bpm (atrial) & 120 to 200 bpm (ventricular) -Rhythm: highly irregular -QRS: usually normal, can be abnormal -P wave: no discernible p wave, irregular undulating waves that vary in amplitude & shape (f waves) -PR interval: cannot be measured -P:QRS ratio: many:1
Characteristics of normal sinus rhythm.
-Rate: 60 to 100 bpm (ventricular & atrial) -Rhythm: regular (ventricular & atrial) -QRS: usually normal, can be regularly abnormal -P wave: normal & consistent, always in front of QRS -PR interval: consistent, between 0.12 and 0.20 seconds -P:QRS ratio: 1:1
Medical management of the patient having an allergic or anaphylactic reaction.
-Respiratory & cardiovascular functions are evaluated -CPR/oxygen during cardiac arrest -Epinephrine 1:1000 given subQ -Antihistamines & corticosteroids as adjunct therapy -IV fluids, volume expanders, vasopressors -Monitor for rebound reaction
Management of the patient with Addison's disease. (medical management)
-Restoring blood circulation, administering fluids & corticosteroids, monitoring vital signs, & placing patient in recumbent position with legs elevated -Administering hydrocortisone, vasopressors (if hypotension persists), & antibiotics if needed -If adrenal glands do not regain function, the patient will require lifelong replacement of corticosteroids & mineralocorticoids
Patient teaching for the patient with a diagnosis of asthma. (meds)
-SABAs are used for prompt relief of airflow obstruction -Corticosteroids, LABAs are used to control persistent asthma -Follow Asthma Action Plan -Use a spacer
Clinical manifestations of patient with a diagnosis of pneumonia.
-Sudden onset of chills -Rapidly rising fever -Pleuritic chest pain aggravated by deep breathing/coughing -Tachypnea & other signs of respiratory distress -Poor appetite -Purulent or rusty/blood-tinged sputum
Management of the patient experiencing an acute myocardial infarction. (meds)
-Supplemental oxygen -Aspirin -Nitroglycerin -Morphine (monitor BP/RR) -Beta-blockers (with dysrhythmias/after hemodynamics are stable) -Unfractionated heparin/LMWH (prevent further clot formation) -ACE inhibitor (within 36 hours) -Statin
Management of care for the patient receiving hemodialysis. (patient teaching)
-Treatment is usually required three times a week
Management of the patient who is experiencing angina. - Nitroglycerin (pharmacology)
-Vasodilator that improves blood flow to the heart muscle & relieves pain -Dilates veins primarily causing blood to pool throughout the body & less blood to return to the heart (reducing preload) -Lower BP & decrease afterload which decrease myocardial oxygen demand
A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care? A) Fatigue Related to Anemia B) Risk for Ineffective Tissue Perfusion Related to Venous Thromboembolism C) Acute Confusion Related to Increased Serum Ammonia Levels D) Risk for Ineffective Tissue Perfusion Related to Increased Hematocrit
A
A nurse has asked the nurse educator if there is any way to predict the severity of a patient's anaphylactic reaction. What would be the nurse's best response? A) "The faster the onset of symptoms, the more severe the reaction." B) "The reaction will be about one-third more severe than the patient's last reaction to the same antigen." C) "There is no way to gauge the severity of a patient's anaphylaxis, even if it has occurred repeatedly in the past." D) "The reaction will generally be slightly less severe than the last reaction to the same antigen."
A) "The faster the onset of symptoms, the more severe the reaction." The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction: the faster the onset, the more severe the reaction. None of the other statements is an accurate description of the course of anaphylactic reactions.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immune complex (type III) D) Delayed-type (type IV)
A) Anaphylactic (type 1) The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? A) Assess for signs and symptoms of anaphylaxis. B) Assess for erythema and urticaria. C) Administer an OTC antihistamine. D) Administer epinephrine.
A) Assess for signs and symptoms of anaphylaxis. If a patient is experiencing an allergic response, the nurse's initial action is to assess the patient for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply. A) Decreased protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction E) Vitamin D supplementation
A) Decreased protein intake B) Decreased sodium intake D) Fluid restriction Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium intake is usually limited, not increased, and there is no particular need for vitamin D supplementation.
Following an addisonian crisis, a patient's adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A) Episodes of high psychosocial stress B) Periods of dehydration C) Episodes of physical exertion D) Administration of a vaccine
A) Episodes of high psychosocial stress
A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis? A) Hemodialysis is a treatment option that is usually required three times a week. B) Hemodialysis is a program that will require you to commit to daily treatment. C) This will require you to have surgery and a catheter will need to be inserted into your abdomen. D) Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again.
A) Hemodialysis is a treatment option that is usually required three times a week. Hemodialysis is the most commonly used method of dialysis. Patients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo successful kidney transplantation. Treatments usually occur three times a week for at least 3 to 4 hours per treatment.
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? A) Increased eosinophils B) Increased neutrophils C) Increased serum albumin D) Decreased blood glucose
A) Increased eosinophils Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in patients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.
A) Inform the physician and assess the patient for signs of infection Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary care provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the physician would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.
The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? A) Maintain aseptic technique when administering dialysate. B) Wash the skin surrounding the catheter site with soap and water prior to each exchange. C) Add antibiotics to the dialysate as ordered. D) Administer prophylactic antibiotics by mouth or IV as ordered.
A) Maintain aseptic technique when administering dialysate. Aseptic technique is used to prevent peritonitis and other infectious complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection.
A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis
A) Respiratory acidosis The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.
A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position? A)Sitting upright, leaning forward slightly B)Low Fowler's, with the neck slightly hyperextended C)Prone D)Trendelenburg
A) Sitting upright, leaning forward slightly The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe.
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. E) The cuffs absorb dialysate
A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. Most of these catheters have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. They do not absorb dialysate.
A patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? A) Type I B) Type II C) Type III D) Type IV
A) Type I Urticaria (hives) is a type I hypersensitive allergic reaction
A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? A)Pets B)Lack of sleep C)Psychosocial stress D)Bacteria A)Pets Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Lack of sleep, stress, and bacteria are not common triggers for asthma attacks.
A)Pets Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Lack of sleep, stress, and bacteria are not common triggers for asthma attacks.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.
Ans: A Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? A) Obstructed arterial blood flow to the forearm and hand B) Simultaneous pressure on the ulnar and radial nerves C) Irritation of Merkel cells in the patient's skin surfaces D) Uncontrolled muscle spasms in the patient's forearm
Ans: A Feedback: Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B) Morphine sulphate, oxygen, and bed rest C) Oxygen and beta-adrenergic blockers D) Bed rest, albuterol nebulizer treatments, and oxygen
Ans: B Feedback: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises
Ans: B Feedback: After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.
A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.
Ans: C
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen
Ans: C Feedback: The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.
The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barré syndrome D) Overdose of amphetamines
Ans: C Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome
Ans: C Feedback: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A) A patient with extensive burns B) A patient who has a diagnosis of acute respiratory distress syndrome C) A patient who suffered multiple trauma in a workplace accident D) A patient who is being treated for septic shock
Ans: D Feedback: Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause.
A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patients level of consciousness frequently. D) Closely monitor intake and output.
Ans: D Feedback: The patient with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the patients intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output.
A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as ordered C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation
Ans: D Feedback: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action? A) Warm the patient's foot and determine whether circulation improves. B) Reposition the patient with the affected foot dependent. C) Reassess the patient's neurovascular status in 15 minutes. D) Promptly inform the primary care provider.
Ans: D Feedback: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness
Ans: D, E Feedback: Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age 65
B
A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Butterfly rash C) Jaundice D) Skin sloughing
B
A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout
B
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A)Rescue inhalers B)Anti-inflammatory drugs C)Antibiotics D)Antitussives
B) Anti-inflammatory drugs Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.
A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patient's respiratory status. How should the nurse evaluate the patient's respiratory status? Select all that apply. A) Facilitate lung function testing. B) Assess breath sounds. C) Measure the child's oxygen saturation by oximeter. D) Monitor the child's respiratory pattern. E) Assess the child's respiratory rate.
B) Assess breath sounds. C) Measure the child's oxygen saturation by oximeter. D) Monitor the child's respiratory pattern. E) Assess the child's respiratory rate. The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? A)Encouraging patients to carry a corticosteroid rescue inhaler at all times B)Educating patients about recognizing and avoiding asthma triggers C)Teaching patients to utilize alternative therapies in asthma management D)Ensuring that patients keep their immunizations up to date
B) Educating patients about recognizing and avoiding asthma triggers Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? A) The decision is certainly yours to make, but be sure not to make a mistake. B) Kidney transplants in patients your age are as successful as they are in younger patients. C) I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare. D) Have you talked this over with your family?
B) Kidney transplants in patients your age are as successful as they are in younger patients. Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the elderly. However, the outcome is comparable to that of younger patients. The other listed options either belittle the patient or give the patient misinformation.
A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism
B) Maintaining and monitoring the patients fluid balance
The nurse is caring for a patient at risk for an Addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. A) Epistaxis B) Pallor C) Rapid respiratory rate D) Bounding pulse E) Hypotension
B) Pallor C) Rapid respiratory rate E) Hypotension
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care? A) Monitor the patient's level of consciousness. B) Protect the patient's airway. C) Provide psychosocial support. D) Administer medications as ordered.
B) Protect the patient's airway. Anaphylaxis severely threatens a patient's airway; the nurse's priority is preserving airway patency and breathing pattern. This is a higher priority than other valid aspects of care, including medication administration, psychosocial support, and assessment of LOC.
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action? A) Advance the catheter 2 to 4 cm further into the peritoneal cavity. B) Reposition the patient to facilitate drainage. C) Aspirate from the catheter using a 60-mL syringe. D) Infuse 50 mL of additional dialysate.
B) Reposition the patient to facilitate drainage. If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate.
The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? A) The possibility of precipitous weight gain B) The need for lifelong steroid replacement C) The need to match the daily steroid dose to immediate symptoms D) The importance of monitoring liver function
B) The need for lifelong steroid replacement
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.
C
A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response? A) Taking care of you in the best way involves seeing you face to face. B) Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. C) Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. D) Taking care of you in the best way involves drawing blood work every month.
C
A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most appropriate action? A) Reposition the patient and auscultate posteriorly. B) Document the presence of S3 and monitor the patient closely. C) Inform the primary care provider that a friction rub may be present. D) Inform the primary care provider that the patient may have pneumonia.
C
A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? A) Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels. B) Ill try to be as physically active as possible between flare-ups. C) Ill make sure to monitor my body temperature on a regular basis. D) Ill stop taking my steroids when I get relief from my symptoms.
C
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patients level of consciousness (LOC). B) Assess the patients extremities for signs of cyanosis. C) Assess the patients oxygen saturation level. D) Review the patients hemoglobin, hematocrit, and red blood cell levels.
C
The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer
C
A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A)Administer corticosteroids by metered dose inhaler B)Administer inhaled anticholinergics C)Administer an inhaled beta-adrenergic agonist D)Utilize a peak flow monitoring device
C) Administer an inhaled beta-adrenergic agonist Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.
A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? A)Dyspnea and increased respiratory secretions B)Nausea and vomiting C)Cough and oral thrush D)Fatigue and decreased level of consciousness
C) Cough and oral thrush Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.
A patient's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patient's statements suggests a need for further education? A)"I know that these drugs can sometimes make my heart beat faster." B)"I've heard that this drug is particularly good at preventing asthma attacks during exercise." C)"I'll make sure to use this each time I feel an asthma attack coming on." D)"I've heard that this drug sometimes gets less effective over time."
C) I'll make sure to use this each time I feel an asthma attack coming on. LABAs are not used for management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.
The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face
C) Muscle weakness
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? A)Lung cancer B)Cystic fibrosis C)Respiratory failure D)Hemothorax
C) Respiratory failure Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.
A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A)Teach the patient strategies for promoting diaphragmatic breathing. B)Administer supplementary oxygen by simple face mask. C)Teach the patient to perform airway suctioning. D)Assist the patient in developing an appropriate exercise program.
C) Teach the patient strategies for promoting diaphragmatic breathing. The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in patients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate.
A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A)Decrease SA node conduction B)Control ventricular heart rate C)Improve oxygenation D)Maintain anticoagulation
Control ventricular heart rate********* Feedback: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.
An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration
D
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow? A) The patient must not have received an immunization within 7 days. B) The nurse should administer albuterol 30 to 45 minutes prior to the test. C) Prophylactic epinephrine should be administered before the test. D) Emergency equipment should be readily available.
D) Emergency equipment should be readily available. Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.
A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? A)To ensure long-term prevention of asthma exacerbations B)To cure any systemic infection underlying asthma attacks C)To prevent recurrent pulmonary infections D)To gain prompt control of inadequately controlled, persistent asthma
D) To gain prompt control of inadequately controlled, persistent asthma Prednisone is used for a short-term (3-10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A)Defibrillation B)ECG monitoring C)Implantation of a cardioverter defibrillator D)Angioplasty
Defibrillation*** Feedback: Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.
The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document? A)ECG to compare time of onset of VT and onset of device's shock B)ECG so physician can see what type of dysrhythmia the patient has C)Patient's level of consciousness (LOC) at the time of the dysrhythmia D)Patient's activity at time of dysrhythmia
ECG to compare time of onset of VT and onset of device's shock***** Feedback: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.
Management of the patient receiving peritoneal dialysis. - Normal exchange times
Fill: 5-10 mins Dwell: prescribed Drainage: 10-20 mins
The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the patient's most recent cardiac imaging, which notes the presence of scarring on the atria. How should the nurse best respond to this finding? A)Recognize that the procedure was unsuccessful. B)Recognize this as a therapeutic goal of the procedure. C)Liaise with the care team in preparation for repeating the maze procedure. D)Prepare the patient for pacemaker implantation. Recognize that the procedure was unsuccessful.
Recognize this as a therapeutic goal of the procedure.***** Feedback: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of the electrical impulse. Consequently, scar formation would constitute a successful procedure. There is no indication for repeating the procedure or implanting a pacemaker.
