\u2022Rationale: Assessing how often the patient swallows after nasal surgery is a priority because
repeated swallowing may indicate posterior nasal bleeding. A penlight is used to examine the
throat for bleeding.
QUESTION
Mr. Sherwood is concerned because his nose keeps bleeding. He asks the nurse, “Can you tell
me again what I can do to keep my nose from bleeding?”
How should the nurse respond to Mr. Sherwood’s question?<\/li>\n<\/ul>\n\n\n\n
Mr. Sherwood is discharged home. The nurse talks with him and his family on how to care for
Mr. Sherwood after discharge.
What are some talking points that the nurse should include in discharge teaching for Mr.
Sherwood and his family?
Answer:
\u2022Answer: The nurse may suggest that the patient keep his mouth open while sneezing, not bend
over, and avoid coughing and vomiting. Avoid taking aspirin and NSAIDs while the nose heals.
Avoid straining during bowel movements.
\u2022Rationale: These activities increase blood pressure causing fragile blood vessels to break and
bleed. Teaching the patient to avoid these activities will prevent increase in pressure. Laxatives
or stool softeners may help to ease bowel movements. Aspirin and NSAIDs increase bleeding
potential.
\u2022
\u2022The nurse may include instructing the patient to stay in a semi-Fowlers’ position, to move
slowly, to keep all follow-up appointments, to call his provider if fever develops, and to use a
humidifier.
\u2022Rationale: Providing discharge instructions to Mr. Sherwood and his family allows them to be
involved in his care and increases compliance and health care outcomes. Correct positioning and
moving slowly decrease chances of bleeding and edema to the area. Following up with the
provider allows opportunity for extension of care to complete recovery and identification of
problems early.
QUESTION
Asthma occurs in two ways:
Answer:
\u2022Inflammation
\u2022Airway hyperresponsiveness leading to bronchoconstriction
Asthma is classified based on how well controlled the symptoms are and the patient’s response to
the medications to treat the disease process. Status asthmaticus is a severe life-threatening
condition that requires prompt intervention
QUESTION
Pathophysiology of asthma
Answer:<\/p>\n\n\n\n
\u2022Intermittent and reversible airflow obstruction affecting airways only, not alveoli \u2022Check the client’s gag reflex. \u2022Absence of bowel movements \u2022Preventing aspiration \u2022Client takes naproxen sodium (Naprosyn) 1500 mg daily for arthritis pain. \u2022Check the client’s blood sugar level. \u2022”I will elevate my arm on a pillow at night.” \u2022These results may indicate prostate cancer. He should be further evaluated. \u2022”It compresses the urethra, blocking the flow of urine.” Gloves should be worn whenever direct contact with the client’s skin is required. \u2022Malaise \u2022Bleeding esophageal varices \u2022Clay-colored stools \u2022Maintaining NPO status for the client with IV fluids \u2022BMI > 30 \u2022Keep wire cutters readily available at all times. \u2022Heart rate 120 beats\/minute \u202210 seconds Pain, especially with inspiration \u2022Mask \u2022Stagnation \u2022Cloudy CSF, elevated protein \u2022Take medications 45 minutes to one hour before meals \u2022Supine with HOB 30 degrees \u2022The client is coughing pink, frothy sputum Chest discomfort when walking and subsiding with rest \u2022Systolic murmur S3 sound . I will give my canned soups to the food pantry \u2022Wear warm clothing when exposed to cool temperatures Serum amylase, 200 U\/L Pleural effusion PCA morphine sulfate Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time?<\/p>\n\n\n\n Small and frequent meals are best. Administer oxygen via Venturi mask Tracheomalacia Oxygenate the patient with 100% oxygen Encourage the patient to sit in a chair for meals. Clear glucose positive fluid draining from nares Weight loss Respiratory rate Which vital sign or test result requires the nurse’s immediate attention?<\/p>\n\n\n\n Oxygen at 2 L per nasal cannula Prolonged immobility; advancing age; recent surgery. What risk factors are present for VTE?<\/p>\n\n\n\n The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms. Based on these findings, what do you suspect might be happening with the patient?<\/p>\n\n\n\n Place the patient on a bedpan and stay with her until she is finished. aPTT is 1.5 to 2.5 times the control. -“Be sure to have follow-up INR laboratory tests done.” A.Triglycerides 168 mg\/dL Ask the patient to lay on his left side. “Smoking is a major risk factor for coronary artery disease and peripheral vascular disease.”
Airway obstruction
\u2022Inflammation
\u2022Airway hyperresponsiveness
QUESTION
causes of asthma
Answer:
exposure to allergens or irritants; stress, cold, and exercise
QUESTION
Interprofessional Collaborative Care for asthma
Answer:
Assessment: Noticing
\u2022Physical assessment\/clinical manifestations
\u2022Audible wheeze, increased respiratory rate
\u2022Increased cough
\u2022Use of accessory muscles
\u2022”Barrel chest” from air trapping
\u2022Long breathing cycle
\u2022Cyanosis
\u2022Hypoxemia
Symptoms- labored breathing, wheezing, trouble sleeping, frequent cough, feeling tired, feeling
short of breath
Common triggers – pollution, dust, smoke, pet dandner, household chemicals, bacteria, viruses,
mold
QUESTION
Assessment: Noticing for asthma
Answer:
Laboratory assessment
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The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse’s best action?<\/p>\n\n\n\n
The clinic nurse reviews the record of a three-day-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom is most likely led the mother to seek health care for the infant?<\/p>\n\n\n\n
A client has esophageal cancer. Which intervention by the nurse takes priority?<\/p>\n\n\n\n
The nurse us caring for a client who is at risk for developing gastritis. Which finding from the client’s history leads the nurse to this conclusion?<\/p>\n\n\n\n
The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse’s priority action?<\/p>\n\n\n\n\n
The nurse is preparing a teaching plan for a client who is scheduled to undergo mammography for the first time. What instruction by the nurse is accurate?<\/li>\n<\/ul>\n\n\n\n
A client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding of managing this problem?<\/p>\n\n\n\n
A client’s laboratory findings reveal a high prostate-specific antigen level. How does the nurse interpret this information?<\/p>\n\n\n\n
A client with BPH asks why his enlarged prostate is causing difficulty with urination. Which is the nurse’s most accurate response?<\/p>\n\n\n\n
A client has syphilis with sores present. What precautions are necessary for the nurse to take when caring for this client?<\/p>\n\n\n\n
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?<\/p>\n\n\n\n
A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for?<\/p>\n\n\n\n
The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration?<\/p>\n\n\n\n
The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client?<\/p>\n\n\n\n
The nurse assesses the client with cystic fibrosis for all of the following clinical manifestations associated with this disease except:<\/p>\n\n\n\n
Which of the following is a priority education for a client who is being discharged after surgical intervention for a mandibular fracture?<\/p>\n\n\n\n
The nurse is getting ready to administer Albuterol inhaler. Which of the following symptoms might indicate a need to contact the healthcare provider before administering this medication?<\/p>\n\n\n\n
\u2022The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?<\/p>\n\n\n\n
\u2022The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?<\/p>\n\n\n\n
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?<\/p>\n\n\n\n
You are taking care of 50-year-old client who seems frustrated. He resents his younger counterparts, associates with his family to meet his needs, and is not interested in volunteering in community events. This client is likely experiencing<\/p>\n\n\n\n
A lumbar puncture is performed on a client suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?<\/p>\n\n\n\n
The nurse should instruct the client with myasthenia gravis to<\/p>\n\n\n\n
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?<\/p>\n\n\n\n
The nurse is taking care of a client who has experienced a myocardial infarction (MI). The health care provider should be notified when the nurse notes which finding?<\/p>\n\n\n\n
The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina?<\/p>\n\n\n\n
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?<\/p>\n\n\n\n
A nurse is assessing a patient with heart failure and auscultates a heart sound right after the second heart sound. How will the nurse document this heart sound?<\/p>\n\n\n\n
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?<\/p>\n\n\n\n
The nurse is providing disease management education to a client with Raynaud’s disease. What intervention does the nurse suggest to prevent complications if this disease?<\/p>\n\n\n\n
A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has “eaten and drunk quite a bit.” He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis.<\/p>\n\n\n\n
Diabetes mellitus
Pancreatic infection
Acute kidney failure
In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.)<\/p>\n\n\n\n
When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases.<\/p>\n\n\n\n
The patient has been NPO but is now tolerating food.
What education will the nurse provide regarding nutrition?<\/p>\n\n\n\n
A patient with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing intervention is most appropriate?<\/p>\n\n\n\n
The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication?<\/p>\n\n\n\n
While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?<\/p>\n\n\n\n
The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform?<\/p>\n\n\n\n
The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding requires immediate intervention?<\/p>\n\n\n\n
Nasal mask to deliver BiPAP
A change in sleeping position
Position-fixing device that prevents tongue subluxation
The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.)<\/p>\n\n\n\n
The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows:
BG\u2014239 mg\/dL BP\u2014138\/88 mm Hg
HR\u2014128 RR\u201436 breaths\/min
O2 saturation\u201488% (room air) Temperature\u2014101.6\u00ba F<\/p>\n\n\n\n
After consulting with the provider, the following orders are received:
Full liquid diabetic diet
IV fluids 1000 mL .9 NS at 60 mL\/hr
Oxygen at 2 L per nasal cannula
Blood cultures \u00d7 3 and urinalysis
Tylenol grain \u00d7 every 4 hour for temperature above 101\u00ba F
Cefazolin (Ancef) 1 g IVP every 8 hour<\/p>\n\n\n\n
A 65-year-old woman is brought to the ED by her husband with new-onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up.<\/p>\n\n\n\n
During triage, the following vital signs and assessments are noted
Temperature\u201499.6\u00ba F BP\u201480\/44 mm Hg
P\u2014126 (sinus tachycardia) R\u201428 and labored
O2 saturation\u201484% (room air) Crackles bilaterally
Petechiae across chest and in axillae<\/p>\n\n\n\n
While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP).<\/p>\n\n\n\n
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol.
Which finding indicates that the heparin infusion is therapeutic?<\/p>\n\n\n\n
-“Report any bruising or bleeding to your provider.”
-.”Use a soft toothbrush to brush your teeth and an electric razor to shave your legs.”
Three days later, the provider prepares to discharge the patient on warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select all that apply.)<\/p>\n\n\n\n
B.HDLs 40 mg\/dL
A patient has recently been admitted with a diagnosis of coronary artery disease. What lab assessments would the nurse anticipate? (Select all that apply.)<\/p>\n\n\n\n
The nurse is assessing a patient’s heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate?<\/p>\n\n\n\n
A patient who smokes asks the nurse, “Smoking just hurts my lungs, not my heart, right?” Which nursing response is appropriate?<\/p>\n\n\n\n