ADULT HEALTH Flashcards

Question

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client's respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding? A. Finish counting the client's respirations B. Empty the water-seal chamber C. Assist the client with incentive spirometry D. Notify the charge nurse

Answer 1

Explanation Answer: A A is correct. It is appropriate for the nurse to simply finish counting the client's respirations and continuing to monitor them as normal. Fluctuations of the water in the water-seal-chamber with inspiration and expiration is a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and decrease when they breathe out. This is due to changes in intrathoracic pressures. B is incorrect. The nurse should not empty the water-seal chamber. This would cause a break in the closed drainage system and could result in injury to the client. C is incorrect. It is not necessary for the nurse to help the client with incentive spirometry based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to assess the client as normal. D is incorrect. It is not necessary for the nurse to notify the charge nurse based on this finding. The nurse has noted an expected finding of the chest-tube system and can continue to monitor the client as normal. NCSBN Client Need: Topic: Reduction of Risk Potential Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures Subject: Adult Health Lesson: Respiratory

Answer 2

Explanation Choice B is correct. These signs and symptoms may indicate nerve injury or impaired circulation or thrombophlebitis/ venous thrombosis. These conditions may be related to injury during surgery or post-surgical complications. The nurse should let the patient lie down and limit the activity and call the physician. Choice A is incorrect. While elevating the client’s leg on a pillow may be beneficial to reduce swelling and discomfort by increasing venous return, fluids should be withheld until the physician is notified. In this post-surgical patient, if any injury is suspected, procedures may be required, and it may be necessary that the client refrains from oral intake before some methods. Choice C is incorrect. If the diagnosis is acute venous thrombosis, rubbing or massaging the leg is contraindicated since it may dislodge the thrombus. If an alternative diagnosis such as nerve-related discomfort is proven, rubbing/ massaging may ease the pain. However, until the physician is notified, and deep vein thrombosis is excluded, such measures should be withheld. Choice D is incorrect. This option can be a distractor since early ambulation is often encouraged in post-operative patients. However, this patient has symptoms, and the diagnosis needs to be established. Acute Deep vein thrombosis (DVT) is included in the differential diagnosis of the symptoms reported by this post-operative patient. In acute DVT, most clinicians historically preferred recommending bed rest to avoid dislodgement of the possible thrombus. Recent studies have shown that early ambulation can be recommended even for those with new DVT since there was no increased incidence of pulmonary embolism in patients with DVT who were ambulatory and because early ambulation decreased the duration and severity of the symptoms. Irrespective of this debate, the first step for the nurse is to tell the client to say in bed and call the physician because the diagnosis is not established yet, and other diagnoses such as nerve injury and circulatory injury have not yet been excluded. NCSBN Client need Topic: Reduction of Risk Potential; Subtopic: Potential for complications from Surgical Procedures Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination.20thEdition

Answer 3

Explanation Choices A, B, and F are correct.The assessment criteria used to determine the need for Total Parenteral Nutrition (TPN) include an inability to achieve or maintain enteral access. Examples include motility disorders, intractable diarrhea ( Choice A), impaired absorption of nutrients from the gastrointestinal tract ( Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient’s response to surgery. TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, a tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections. Choice C is incorrect. For short-term use (less than four weeks), a nasogastric or gastrointestinal route is usually selected. Choice D is incorrect. A gastrostomy is a preferred route to deliver enteral nutrition in a comatose patient because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Choice E is incorrect. Patients who refuse to take food should not be force-fed nutrients against their will. NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation Reference: The Art and Science of Person-Centered Nursing Care (Wolters/Klewer); Chapter 35: Nutrition; Lesson: Providing Parenteral Nutrition

Answer 4

Explanation Correct Answers are A, B, C, and D. Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/ impaired oxygenation. Post-operatively, the client may not be able to take deep inspiration due to pain from the movement of abdominal muscles. This impaired expansion of alveoli leads to the accumulation of secretions/ mucus plug, decreased surfactant and eventually, obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include: Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry. An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion. The above interventions are aimed at preventing Atelectasis. However, the nurse should be aware of detecting atelectasis if it did end up happening. Physical exam findings assist in the diagnosis and include fever and decreased breath sounds on the side of atelectasis. In the case of complete atelectasis/ collapse, the trachea/ mediastinum may be shifted to the same side due to the pull by a collapsed lung. Atelectasis in the postoperative period is referred to as "resorption atelectasis" but the nurse should also be aware of other types in different client scenarios. Once the nurse detects atelectasis, treatment interventions from a nurseâ€™s perspective include: - Use of Incentive Spirometry (IS) - IS mimics the natural process of sighing or yawning. It encourages the patient to take slow and deep breaths. The result of this process is decreased pleural pressure, increased lung expansion, and improved gas exchange. Regular repetition of IS can prevent or even reverse the atelectasis. Supportive devices to assist with deep coughing. Chest physiotherapy which includes tapping on the chest to loosen mucus Mobilizing the patient early including encouraging sitting up in bed, sitting over the edge of the bed, standing, or assisted ambulation. Postural drainage - to achieve this, the body is positioned with the head lower than the chest to promote gravitational drainage of the mucus from the bottom of the lungs. (Note this position is for treatment of atelectasis and is different from the semi-recumbent area used to prevent atelectasis) Bronchoscopy may be ordered in certain cases by the physician to remove the mucus plug if the patient is not showing improvement despite the above non-invasive measures.

Answer 5

Explanation D is correct. The client should be taught ways on how to prevent and manage dumping syndrome. The client should be instructed to have small, frequent meals; maintain a high protein, high fat, low carbohydrate, and dry diet. The client should be notified to eat in a recumbent or semi-recumbent position. Such positioning during eating delays gastric emptying. A is incorrect. The client is instructed to lie down after meals to delay gastric emptying. B is incorrect. The client should not drink any water 1 hour before eating, with food, or 2 hours after eating to prevent dumping syndrome. C is incorrect. The client should limit carbohydrate intake to prevent dumping syndrome. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Answer 6

Explanation Answer: 79 mLs This is a simple question where the stem contains much more information that you actually need to solve the problem. You must identify what exactly the question is asking, and use only the information needed to solve the problem. Donâ€™t overthink it! The question asks how much water the nurse will add to the can of formula. The order reads Â¾ strength, and the can of formula is 237 mLs. The nurse must add 79 mLs of water to dilute the formula to Â¾ strength. To find this answer, divide 237 by 3. This will give you 3 parts formula, 1 part water - or Â¾ strength. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Pharmacological therapies

Answer 7

Explanation Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3–5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, and constipation, and risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3–4 months [68]. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months; and gaining all of the importance back in less than five years [69]. LCDs are not as extreme, and with almost twice as many calories allowed (1200–1500 kcal/day), the weight loss is modest. The correct answer is C. Very Low-Calorie Diets are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. A is incorrect. The VLCD is not intended to be a long-term treatment measure. B is incorrect. VLCD consists of high levels of quality proteins. D is incorrect. The food on a VLCD is not pureed. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation

Answer 8

xplanation Correct Answer is D Correct. Hypercalcemia, a hazard of immobility and complete bed rest, can be prevented with the use of a tilt table to provide weight-bearing and the prevention of the demineralization of the bones as occurs during periods of immobility and complete bed rest. As the bones demineralize, the calcium leaves the bones and enters the blood to create hypercalcemia. Choice A is incorrect. Renal calculi formation, a hazard of immobility and complete bed rest, cannot be prevented with measures to increase urinary alkalinity because it is alkaline urine that leads to renal calculi formation. Choice B is incorrect. Hypocalcemia can be prevented by calcium supplements. But the question is asking about Hazard of immobility. Hypocalcemia is not a hazard of immobility and complete bed rest; however, hypercalcemia is. Choice C is incorrect. Venous dilation, a hazard of immobility and complete bed rest, cannot be prevented with the application of heat; heat is a vasodilator and, as such, would only add to the venous dilation. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition)

Answer 9

Explanation Answer: 150 ( 150k = 150,000) The normal range for a platelet count is 150,000 to 400,000 cells/mm3. Platelets are produced by the bone marrow, though, so in a patient with cancer of the bone marrow, the nurse would expect a low platelet count. This patient will be on bleeding precautions and need careful monitoring. NCSBN Client Need Topic: Reduction of Potential Risk Subtopic: Laboratory Values Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 117

Answer 10

Explanation Choice C is correct. The appropriate expected goal or expected outcome for this client, in terms of the gastrointestinal system, who is receiving an enteral feeding every 4 hours, is that the client will be free of dumping syndrome, which can further increase the client’s nutritional deficits. Simply stated, dumping syndrome is the very rapid and quick movement of foods and fluids through the stomach and then into the small intestine; the feed is then mostly undigested and eliminated through the gastrointestinal tract. Although dumping syndrome is primarily associated with gastric bypass surgery, it can also occur as a result of enteral bolus feedings. Because "dumping syndrome" is one of the main complications that accompany enteral feeding,you must ensure to prevent it by implementing appropriate nursing interventions which include giving formula at room temperature and increasing the feeding rate gradually. Choice A is incorrect. “The client will be free of any insertion site infection” may be an appropriate expected goal or expected outcome for this client who is receiving an enteral feeding every 4 hours. Still, this outcome is not related to the client’s gastrointestinal system. Choice B is incorrect. “The nurse will measure residual before each feeding” is an appropriate nursing intervention, but it is not an expected goal or expected outcome. Choice D is incorrect. “The nurse will administer no more than 200 mL for each feeding” is not an expected goal or expected outcome. Moreover, the nurse can administer more than 200 mL for each feeding. The volume of each food is typically from 250 to 400 ml per feeding. Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0; ATI Nursing Education.

Answer 11

Explanation The correct answers are B, C, and E. COVID-19 is indeed spread through droplet transmission(Choice B). This means that when someone coughs or sneezes, the secretions have the virus and can then infect another person. The droplets can also live on a surface and then be transmitted to another person. Percurrent CDC guidelines, Droplet precautions should be used by healthcare personnel to prevent the spread of the infection. But if a patient will be undergoing aerosolizing procedures like intubation, nebulizations, etc; airborne precautions with negative pressure isolation rooms are used. The patients that are most likely to suffer significantly from COVID-19 are those who are immunocompromised (Choice C)and have a weak immune system. This includes the geriatric population, the chronically ill, patients going through chemotherapy or other cancer treatments, and patients with other pre-existing conditions like Diabetes/Cardiac issues. These patients have a high risk of complications and a high risk of dying from COVID-19. When available, N95 masks (Choice E) are preferred while attending to COVID-19 patients. The 'N95' designation means that when subjected to careful testing, the respirator blocks at least 95 percent of tiny (0.3 microns) test particles. These masks are typically used in Airborne precautions, but in dealing with confirmed COVID-19 patient, N95 is preferred over face mask as per current CDC guidelines. However, due to a shortage of N95, CDC is currently allowing Surgical masks (Face masks) as well if N95 is not available. However, when specific aerosolizing procedures are being done (nebulization, intubation) on a COVID19 patient, N95 masks MUST ALWAYS BE used. Choice A is incorrect. The COVID-19 disease is NOT caused by the Staphylococcus aureus bacteria. COVID-19 is the name of the disease caused by the SARS-COV2 virus. This stands for sudden acute respiratory syndrome coronavirus 2. Because this is a viral illness, antibiotics will not be effective in treating the disease. The Staphylococcus aureus bacteria is a dangerous, gram-positive bacteria that often cause skin infections. Choice D is incorrect. These are not the most common symptoms of COVID-19. Instead, fever, cough, and shortness of breath are the most common symptoms concerning for COVID-19. This is a respiratory illness, so monitor for respiratory symptoms such as cough, shortness of breath, sneezing, dyspnea, etc. The following video describes COVID-19 in detail: NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Infection control and safety. Reference: 2019 Novel Coronavirus (2019-nCoV) Situation Summary. (2020, March 9). Retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/summary.html

Answer 12

Explanation Answer: A, B, and C A is correct. Before beginning a cycled tube feeding, it is appropriate for the nurse to flush the nasogastric tube with saline. This allows for verification that the tube is patent, and that the formula will freely flow into the clientâ€™s stomach during the feeding. B is correct. It is extremely important to always verify the placement of the nasogastric tube before putting anything in it. If the tube has moved and the tip of it is no longer in the stomach, the feeding could be aspirated causing serious problems such as pneumonia. The gold-standard to verification of tube placement is visualization on an x-ray. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nursing staff can check that the tube has not moved and remains in the stomach prior to each feeding. C is correct. It is appropriate to elevate the head of the bed prior to any tube feeding. This allows gravity to help the tube feeding flow into the stomach and prevent reflux. For clients receiving a bolus feeding, a high-Fowler's position is preferred, and for clients receiving a cycled or continuous feeding, a semi-Fowlerâ€™s position is preferred. D is incorrect. It is not necessary for the nurse to instruct the client to remain in bed for the duration of their tube feeding. Some clients may prefer to, but it is up to them. They may like to get up to the chair or sit up, and can get up to ambulate to the restroom etc. if appropriate. NCSBN Client Need: Reduction of Risk Potential Topic: Potential for Complications of Diagnostic Tests/Treatments/procedures Subtopic: Coordinated care Subject: Fundamentals Lesson: Safety

Answer 13

Explanation Correct Answer is C, D, E, and F Folate is found in liver, legumes, and leafy green vegetables. Vitamin K is found in leafy green vegetables and liver. Vitamin D is found in fortified milk and fish. Pantothenic acid B5is found in whole grains, avocado, beans, legumes (lentils), lean chicken, beef, pork, and broccoli. Pantothenic acid is ubiquitous and hence, a deficiency is very rare except in severe malnutrition. Choice A is incorrect. Niacin B3 is found primarily inmeats, liver, fish, legumes, peanuts, coffee, and tea. It is deficient in corn and refined grains. Choice B is incorrect. Riboflavin B2 is found in leafy green vegetables and milk, but not in citrus. Reference: Knippa, Audrey, Sheryl Sommer, Brenda Ball et al. (2010) Nutrition for Nursing 4.0

Answer 14

Explanation Correct Answers are A, B, E and F Correct Answer A. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological that is often needed for decreased client stress and enhanced client coping. Correct Answer B. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor. Correct Answer E. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help with things like transportation and household help. Correct Answer F., An appraisal of social support, is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations. Choice C is incorrect. A physical help social support is not existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Choice D is incorrect. Sensory, social support is nonexistent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice (10th Edition) and Glanz, Karen, Barbara K. Rimer, and K Viswanath. Health Behavior and Health Education: Theory, Research, and Practice. Social Supports. http://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml

Answer 15

Explanation Choice B is correct. This reflects the second stage of Lyme's disease. Neurological and cardiac involvement are hallmarks. Manifestations may include atrioventricular heart block and neuropathy. Ocular manifestations such as Conjunctivitis is seen in 10% cases. Joint pain may be present. The second stage occurs typically around seven weeks after the initial tick bite. It is also referred to as "early, disseminated Lyme's" disease. Choice A is incorrect. The first stage of Lyme's disease usually presents with a red rash the size of a pimple or as a large ring. The patient generally complains of flu-like symptoms. Choice C is incorrect. The third stage of Lyme's disease is characterized by sizeable joint involvement and arthritis ( chronic Lyme arthritis). Knee joints are often involved. Choice D is incorrect. There is no fourth stage in Lyme's disease. NCSBN client need |Topic: Physiologic integrity, physiologic adaptation Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby

ADULT HEALTH Flashcards

(39 cards)