Vsim Brittany Long Complex (Pre/Post)
The nurse is assessing the abdomen of a patient admitted with vaso-occlusive pain crisis. Place the steps of an abdominal assessment in order.
1) Have the patient lie down in a supine position 2) Inspect abdomen for size and shape 3) Auscultate for bowel sounds in all four quadrants 4) Percuss the abdomen working down from the costal margins 5) Lightly palpate the abdomen for tenderness, muscle tone, and turgor 6) Palpate deeply from the lower quadrants upward to the costal margins Rationale:The first step of the assessment is inspection, first with the patient upright and then with the patient lying supine. When assessing the abdomen, the sequence of physical examination is altered. Auscultation is done before percussion and palpation, as manipulation of the lower abdomen may affect the bowel sounds.
The nurse has an order to administer normal saline 20 mL/kg bolus intravenously over 30 minutes. The patient weighs 35 lb. How many milliliters should the nurse prepare to administer? Round the weight in kilograms to nearest the whole number.
320 mL Rationale:Fluid boluses are calculated using the 20 mL/kg formula. Convert pounds to kilograms: 35 ÷ 2.2 = 15.90 kg. Round 15.90 to nearest whole number: 15.90 = 16 kg. Multiply 20 mL/kg by 16 kg: 20 × 16 = 320 mL.
When preparing a 5-year-old patient for indwelling urinary catheter insertion, which of the following demonstrates that the nurse understands developmentally appropriate communication?
A tiny tube will be placed where you go pee-pee. You may feel a pinch. Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening. Using terms such as "if" or "OK" and asking whether the patient wants to do something offer the illusion of a choice when there is not one available. Avoid terms that are too technical or confusing, such as "catheter" or "urethra," which can cause the child to misunderstand what is going to occur. Be honest if a procedure is going to be uncomfortable or cause pain. It is important to let the patient know that it is acceptable to express feelings and get upset or cry if in pain.
The nurse initiates a blood transfusion for a 5-year-old patient with acute splenic sequestration. One hour later, the patient appears anxious and complains of chest tightness and headache. Upon further assessment, the nurse finds that the patient's blood pressure is 78/48 mm Hg, temperature is 38.5°C, and urine output appears blood-tinged. The nurse suspects the patient is experiencing which of the following transfusion reactions?
Acute hemolytic reaction Rationale:Any patient receiving a transfusion of blood or blood products is at risk of a transfusion reaction. Transfusion reactions may be immediate, occurring during the transfusion or within several hours of the completion of the transfusion, or delayed. Symptoms of an acute hemolytic reaction include: chills, shaking, fever, nausea and vomiting, chest tightness, headache, flank pain, and pain at the intravenous insertion site. Acute hemolytic reactions can progress to renal failure and shock if intervention is delayed. A septic reaction is indicated by rigors, chills, fever, and shock. A nonhemolytic febrile reaction is indicated by fever and chills. An allergic reaction is indicated by urticaria (hives), flushing, wheezing, and laryngeal edema.
The nurse is caring for a patient with acute splenic sequestration in hypovolemic shock. The patient has adequate respiratory effort and central pulses are present with weak peripheral pulses. Which of the following interventions, as ordered by the primary provider, would be the nurse's first priority?
Administer 20 mL/kg bolus of isotonic crystalloid intravenously Rationale:When caring for a patient in shock, the nurse should first evaluate and manage the airway and breathing and then check for pulses, all of which has been done already in this case. If the patient has poor respiratory effort or is apneic, 100% oxygen should be administered via bag valve mask or endotracheal tube, but this patient has adequate respiratory effort, so use of the bag valve mask is not needed. Once airway and breathing needs are addressed, nursing management of shock focuses on obtaining vascular access and restoring fluid volume. Isotonic fluids such as normal saline or Ringer's lactate should be infused intravenously as a 20 mL/kg bolus rapidly. Blood may be administered to patients in shock if there is an inadequate response to the isotonic crystalloid bolus. After administration of fluid has been initiated, an indwelling urinary catheter should be placed to allow for frequent and accurate monitoring of urinary output. It is important to monitor urine output over several hours to determine whether fluid resuscitation has been effective, but this is not the immediate priority.
The nurse is assessing a 5-year-old patient with sickle cell anemia diagnosed with acute splenic sequestration. The patient is awake and sitting in bed playing video games with her sister. Her vital signs are stable, with a blood pressure of 110/66 mm Hg, heart rate of 98 beats per minute (bpm), respiratory rate of 20 breaths per minute, temperature of 37.5°C oral, and pain rating of 1 out of 5 on the FACES scale. On reassessment, which of the following findings would indicate that the patient's condition is deteriorating? (Select all that apply.)
Blood pressure of 78/48 mm Hg, FACES pain rating of 4 out of 5, Lethargy and pallor Rationale:Clinical manifestations that the patient's condition is worsening include elevated heart rate, decreased blood pressure, alterations in level of consciousness, signs of poor perfusion including pallor, and increased abdominal pain, tenderness, and distention. A heart rate of 86 bpm and temperature of 37.0°C are normal findings.
What would be the highest priority and most appropriate nursing diagnosis for a patient with sickle cell anemia exhibiting signs of splenic sequestration?
Decreased cardiac output related to decrease in circulating blood volume Rationale:In splenic sequestration, the sickled cells become trapped in the spleen. Management of the primary problem through fluid and/or blood product administration will increase cardiac output and circulating blood volume and improve peripheral tissue perfusion. Although pain management is important, assessment and management of circulation and perfusion are the priority. The patient is at risk for shock; however, the current priority is the management of the actual problem of decreased circulation causing poor perfusion.
The nurse is developing a care plan for a patient with sickle cell anemia admitted with vaso-occlusive crisis and acute splenic sequestration. The nurse knows that which of the following can exacerbate the patient's condition and contribute to further sickling? (Select all that apply.)
Distress over the family leaving the patient's bedside, Abdominal pain and tenderness Lack of intake of oral fluids due to patient refusal, Elevated temperature of 39.0°C Rationale:Elevated stress levels, exposure to extremely high or low temperatures, illness, and poorly managed pain can contribute to further sickling and additional pain. Pain should be evaluated frequently and managed by administering analgesics on a scheduled basis. Adequate pain management helps decrease the patient's overall stress level. Decreased oral intake will cause dehydration, resulting in increased blood viscosity and further sickling.
The nurse is preparing to administer a blood transfusion to a 5-year-old patient with acute splenic sequestration. Which of the following steps should be included during the preparation and administration process? (Select all that apply.)
Follow institution protocol for blood transfusion administration and management Use a two-person verification process to verify the patient and blood component Rationale:The nurse should follow institution protocol when administering blood and/or blood components. Blood and blood components should be verified by two nurses using a two-person verification process to identify the patient, check the blood type, and confirm the label on the blood component per institution protocol. The blood transfusion should be initiated within 30 minutes of receiving the blood component from the blood bank. Blood should be infused slowly for the first 15 minutes and the nurse should remain at the bedside to monitor the patient closely. If the patient tolerates the transfusion, the infusion rate will be increased per institution protocol. If a transfusion reaction occurs, the blood transfusion should be stopped and the patient should be monitored closely following institution protocol to manage a transfusion reaction.
The nurse is providing discharge teaching for a patient and family following a splenectomy after multiple admissions for recurrent splenic sequestration. Which of the following statements by the caregiver indicates that teaching has been effective?
I will make sure her immunizations are current and that she has a flu shot every year to keep her from getting very sick. Rationale:After undergoing a splenectomy, a patient is at high risk for infection and sepsis. The patient and family should be taught to recognize the signs and symptoms of infection and should seek medical attention promptly at the first sign of infection or fever. Prophylactic antibiotics should be taken daily as prescribed to prevent infection. Patients should be immunized against Streptococcus pneumonia, Neisseria meningitidis, and Haemophilus influenza type B to reduce the risk of serious infection and sepsis. A medical alert bracelet should be worn at all times.
The nurse is caring for a patient receiving an intravenous (IV) blood transfusion and observes that the patient is exhibiting signs of an acute hemolytic transfusion reaction. Which of the following actions should the nurse take first
Immediately discontinue the blood transfusion Rationale:In the event of an adverse reaction to a blood transfusion, the transfusion should be discontinued immediately. A secondary IV line should then be started, if not already in place, and normal saline infused to keep the vein open. Fluids should not be infused through the same line as the blood transfusion if reaction is suspected. After infusion of the normal saline has begun, the nurse should reassess the patient's response and monitor for signs of shock. The nurse should also notify the patient's provider and the blood bank of the reaction; however, the priority action is to immediately discontinue the blood transfusion in the event of an acute hemolytic transfusion reaction.
A patient with sickle cell disease admitted with acute splenic sequestration has ketorolac (Toradol) and morphine ordered intravenously for pain management. Which of the following principles should the nurse be aware of when administering ketorolac? (Select all that apply.)
Ketorolac may mask the signs and symptoms of an infection Ketorolac can increase bleeding time and the risk for thrombotic events with prolonged use. Rationale: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) indicated for short-term management of moderately severe, acute pain. The maximum combined duration of parenteral, nasal, and oral therapy is 5 days. NSAIDs may mask signs and symptoms of infection because of their antipyretic and anti-inflammatory actions. Ketorolac and morphine are incompatible intravenously and should not be administered together. Intravenous ketorolac should not be given in conjunction with other forms of ketorolac or other NSAIDs, such as ibuprofen. Ketorolac and other NSAIDs cause increased risk of adverse gastrointestinal events including bleeding, ulceration, and perforation of the stomach or intestines, which is amplified with concurrent use of multiple NSAIDs. NSAIDs can increase bleeding time and may increase the risk of serious thrombotic events, myocardial infarction, or stroke, which can be fatal. The risk may be greater with prolonged use.
A patient with sickle cell anemia who was admitted in vaso-occlusive crisis for leg pain reports stomach pain and is guarding her left side. Which of the following assessments should the nurse perform on this patient? (Select all that apply.)
Observation of level of consciousness Inspection of skin color and temperature Auscultation of heart and lungs Rationale:During vaso-occlusive crisis, patients with sickle cell anemia are at risk for splenic sequestration (trapping of sickled blood cells in the spleen), which causes the spleen to become enlarged (splenomegaly). Deep palpation of the abdomen and spleen could cause further trauma to the spleen and potentially splenic rupture. All of the other assessment components are indicated for this patient.
The nurse is reviewing laboratory results for a patient with sickle cell anemia presenting with splenic sequestration. Which of the following results would the nurse expect to be elevated? (Select all that apply.)
Platelet count Bilirubin Reticulocyte count Erythrocyte sedimentation rate Rationale:Expected laboratory findings for a patient with splenic sequestration include decreased hemoglobin, greatly elevated reticulocyte count, increased erythrocyte sedimentation rate, abnormal liver function tests with elevated bilirubin, and increased platelet count.
The nurse is preparing to administer intravenous morphine to a 5-year-old patient with acute splenic sequestration crisis. Which of the following is the priority for the nurse to monitor for with administration?
Respiratory depression Rationale:The nurse should assess the respiratory status frequently in patients receiving morphine. Any decrease in respiratory rate or change in breathing pattern should be noted. Naloxone should be readily available in case of respiratory depression. Patients receiving morphine should also be monitored for abdominal distention and decreased peristalsis, changes in urine output, and reports of itching, but these are not the priority for the nurse to monitor during administration.
The patient with sickle cell anemia has intravenous ketorolac 8 mg scheduled every 6 hours, and the last dose was administered at 0600. At 1200, the nurse prepares ketorolac 8 mg in a syringe and takes it to the room. The patient is alone in the room, sitting in bed watching television and says she lost her identification band. The nurse proceeds to verify the patient's identity by asking her name and medical record number and administers the medication in the patient's peripheral intravenous line. Which right of medication administration has the nurse violated?
Right patient Rationale:It is important to confirm the patient's identity since children may deny their identity in an attempt to avoid an unpleasant situation, play in another child's bed, or remove their identification bracelet. Identity should be confirmed each time a medication is given. The child's name should be verified with the caregiver and additional information should be provided such as date of birth or medical record number according to institution protocol. A 5-year-old would not be expected to remember his or her medical record number.
A nurse is caring for a 5-year-old patient with sickle cell anemia who is exhibiting signs of dehydration. The patient has had limited oral intake in the past 24 hours and is refusing to drink. Which of the following interventions can the nurse incorporate to encourage the child the increase oral fluid intake? (Select all that apply.)
Serve fluids in a decorated cup with a brightly colored straw Offer the patient small amounts of fluids frequently and praise efforts to increase intake Provide the patient with several options to choose from, including a favorite drink Rationale:Providing the patient with a favorite drink and allowing for simple choices such as what cup to drink the fluid in or which color straw to use gives the patient a sense of control. Praise the patient for attempts at eating and drinking. Never punish a child for not eating or drinking. Avoid giving large amounts of fluid at a time. Instead, offer small amounts of liquid frequently. Thin liquids, such as gelatin and carbonated drinks, are easier to ingest than thicker liquids.
The nurse is assessing a patient with sickle cell anemia admitted several days ago with vaso-occlusive pain crisis. Which of the following findings would indicate that the patient is experiencing splenic sequestration crisis? (Select all that apply.)
Tachycardia Greatly decreased hemoglobin Splenomegaly Rationale:Clinical manifestations of splenic sequestration include left-sided abdominal pain, not right-sided, and splenomegaly, tachycardia, and hypotension, not hypertension. Baseline hemoglobin is usually 7 to 10 mg/dL and will be decreased significantly with splenic sequestration.
The nurse is assessing a patient with acute splenic sequestration crisis. Which of the following findings would indicate that the patient is progressing into hypovolemic shock? (Select all that apply.)
Tachycardia and irritability Decreased urine output with dark amber urine Delayed capillary refill time Pale extremities with weak peripheral pulses Rationale: Patients in shock will have cooler extremities with delayed capillary refill. Distal pulses will be weaker than central pulses. Decreased skin elasticity is associated with hypovolemic shock, but is usually a late sign. Urinary output will be decreased in the patient with shock as a result of alterations in blood flow causing decreased kidney perfusion. As shock progresses and cerebral perfusion is decreased, altered levels of consciousness occur. Irritability is an early sign of altered level of consciousness. The heart rate increases in the early stages of shock, but as perfusion is compromised to the heart, the patient will become bradycardic.
The nurse is ordering breakfast for a patient with sickle cell anemia. Which of the following meal choices would be the best to increase folic acid intake?
Whole wheat toast, orange slices, and milk Rationale:Folic acid stimulates normal red blood cell production. It is important to teach patients and families with sickle cell anemia about good nutrition, including foods that are high in folic acid. Foods that are high in folic acid include liver, oranges, whole wheat grains, broccoli, and brussels sprouts.
