EXAM 1 Flashcards
(137 cards)
1
Q
A client with end-stage lung cancer & metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client?
A
Releasing the restraints at least every 2 hours
RATIONALE: The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, re-positioning, and toileting. The restraints must be checked every 30 to 60 minutes. Chemical sedation is also considered a restraint. The least restrictive devices should be used.
2
Q
The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is MOST important in promoting health & safety?
A
“Stop driving when your vision, motor skills, and confidence begin to diminish.”
RATIONALE: Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer. Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.
3
Q
Which older adult client’s living situation typically presents HIGHEST risk for abuse?
A
With adult daughter and grandchildren
RATIONALE: Older adults are often abused by a family member who becomes frustrated or distraught over the burden of caring for the older adult. Prolonged caregiving by a family member is a new and unexpected role for adult children, most often women (as in this case), and is highly stressful. The client living at home alone may suffer from self-neglect, but not from neglect and abuse by another person. Although it is possible that the client living at home with a spouse or in a long-term care facility may suffer from abuse, this is not as common as with clients who live with children and grandchildren.
4
Q
Which result is frequently seen in older adults who have undiagnosed depression?
A
Under-nutrition
RATIONALE: Older adults may respond to depression by not eating, and this can lead to under-nutrition. Many who live alone lose the incentive to prepare or eat balanced diets, especially if they do not “feel well.” Falls are not typically the result of undiagnosed depression. Increased socialization is the antithesis of depression. Older adults, especially those with depression, do not typically go on spending sprees.
5
Q
The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client’s daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do NEXT?
A
Copies the list to the assessment data form
RATIONALE: Copying the list to the assessment data form should be done first. Then, the health care provider should be notified of all drugs, which may or may not be ordered during the client’s stay, depending on the client’s diagnosis. Calling the pharmacy and calling the provider are not the priority for admission. The client may not require all the medications during the hospital stay.
6
Q
At a follow-up visit after repair of a fractured radial bone, an older adult client states, “I am not sleeping at all during the night.” The client’s partner reports that the client is sleeping all day. Which intervention does the nurse suggest?
A
Increasing the client’s daytime activities
RATIONALE: Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal. The client did not report interruptions, but insomnia; placing a “Do not disturb” sign on the door, although it may be effective in increasing “sleep time,” does not address the client’s symptom. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal sleep remedies to try to enhance the effects of other medications is not an appropriate suggestion for the nurse to make.
7
Q
The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as a resource, which drug poses a potential risk for this client?
A
Digoxin (Lanoxin)
RATIONALE: Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.
8
Q
The RN is arriving for night duty at an acute care hospital. Which client does the RN assess FIRST?
A
A 72-year-old who was admitted to the unit with postoperative delirium
RATIONALE: Clients with delirium are at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters. The other clients should be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications.
9
Q
The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning clients in a long-term care setting. Which client requires extreme caution is at GREATEST risk for a skin tear?
A
An 85-year-old client with breathing problems receiving daily doses of prednisone
RATIONALE: UAPs need to use extreme caution when handling members of the old old age group and clients who are on long-term steroid therapy. These groups are most prone to skin tears. This client has both of these high-risk indicators. Although the client with paraplegia has limited mobility, no other factors place the client at high risk for a skin tear. Most total hip repairs have short periods of immobility, with minimal skin breakdown potential; no specific risk factors are evident in this client’s history. Although the client with a recent stroke is at risk for skin breakdown because of age and immobility, fewer risk factors are present than in the older client on steroid therapy.
10
Q
The RN has delegated nursing actions to experienced assistive personnel (UAP) working in a long-term care facility. Which actions require direct supervision by the RN?
A
- Assisting a 70-year-old client who has new-onset leg pain when ambulating
- Repositioning a 69-year-old client who has recently become unconscious
RATIONALE: supervision required when there is a change in the client’s condition, such as a change in the client’s level of consciousness
11
Q
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient’s fall risks. Which of the following is the proper order of steps for the “Timed Get-up and Go Test” (TGUGT)?
A
- Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down
- Have patient rise from straight-back chair without using arms for support
- Begin timing
- Look for unsteadiness in patient’s gait
- Have patient return to chair and sit down without using arms for support
- Check time elapsed
12
Q
At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take FIRST?
A
Prepare for an influx of patients
13
Q
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint?
A
- Identify patient using two identifiers
- Introduce self and ask patient about his feelings of being restrained
- Be sure patient is comfortable with arm in anatomic alignment
- Assess condition of skin where restraint will be placed
- Wrap wrist with soft part of restraint toward skin and secure snugly
14
Q
A nurse knows that the people most at risk for accidental hypothermia are:
A
- People who are homeless
- People with cardiovascular conditions
- The very old
(also: the young, people who have ingested drugs or alcohol in excess)
15
Q
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly?
A
- Inadequate lighting
- Throw rugs
- Multiple medications
- Doorway thresholds
- Cords covered by carpets
16
Q
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation?
A
- Ask the family to stay with the patient if possible
- Inform the family of the risks associated with side-rail use
- Discuss alternatives that are appropriate for this patient with the family
17
Q
You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include?
A
- Drive shorter distances
- Drive only during daylight hours
- Use the side and rearview mirrors carefully
- Keep a window rolled down while driving if has trouble hearing
- Look behind toward the blind spot
18
Q
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?
A
Encouraging use of an overhead trapeze for positioning and transfer
19
Q
To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?
A
Ambulate patient to chair in the hall
20
Q
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
A
Use of incentive spirometer every 2 hours while awake
21
Q
Which of the following are physiological outcomes of immobility?
A
Decreased lung expansion
Also: decreased metabolism, increased cardiac workload, increased oxygen demand
22
Q
A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding:
A
- Bruising
- Bleeding gums
- Coffee ground-like vomitus
23
Q
The nurse evaluates that the NAP has applied a patient’s sequential compression device (SCD) appropriately when which of the following is observed?
A
- Inflation pressure averages 40 mmHg
- Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve
24
Q
The effects of immobility on the cardiac system include which of the following?
A
- Thrombus formation
- Increased cardiac workload
- Orthostatic hypotension
25
A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use?
Four-point
26
Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age?
My granddaughter and I walk together around the high school track 3 times a week
27
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
The patient received an injection of morphine 30 minutes ago for pain
28
The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's:
Use of glucose & fatty acids, thereby decreasing blood glucose level
29
Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association is advocating which of the following?
Require the use of assistive equipment and devices
30
The body alignment of the patient in the tripod position includes the following:
- An erect head and neck
- Straight vertebrae
- Extended hips and knees
- Patient in the tripod position
31
Which of the following is a principle of proper body mechanics when lifting or carrying objects?
- Maintain a wide base of support
| - Encourage patient to help as much as possible
32
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather?
- Patient's weight
- Patient's level of cooperation
- Patient's ability to assist
- Presence of medical equipment
33
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Cleansed wound
34
What is the correct sequence of steps when performing a wound irrigation?
- Place water proof bag near bed
- Fill syringe with irrigation fluid
- Attach angio catheter to syringe
- Position angio catheter over wound
- Use slow continuous pressure to irrigate wound
35
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer?
Unstageable
36
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions?
- Notify the surgeon
| - Cover the area with sterile, saline-soaked towels and immediately
37
Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence?
- Frequent position changes
- Using an incontinence cleaner
- Applying a moisture barrier ointment
38
When is an application of a warm compress to an ankle muscle sprain indicated?
- To relieve edema
| - To improve blood flow to an injured part
39
Which of the following are measures to reduce tissue damage from shear?
- Use a transfer device, e.g. transfer board
- Have head of bed flat when repositioning patients
- Raise head of bed 30 degrees when patient positioned supine
40
The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.)
- With patient on floor, clear surrounding area of furniture or equipment.
- Do not restrain patient; hold limbs loosely if they are flailing.
- Never force apart a patient’s clenched teeth.
Rationale: During a seizure, if a patient is standing, guide to floor. Do not try to place in bed. Do not position the patient supine; instead turn patient onto one side with head tilted slightly. When patient is on the floor, remove any furniture or objects that he or she could strike during tonic and clonic activity. Never force apart a patient’s clenched teeth; you might be bitten. Do not restrain patient; hold limbs loosely if they are flailing. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep.
41
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN?
Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road
RATIONALE: An LPN/LVN would be appropriate to care for an adult client with a facial suture. This nurse would be familiar with wound monitoring for potentially contaminated wounds and would recognize the manifestations of infection.
Conducting an admission assessment and discharge teaching is more complex nursing actions that require RN-level education and scope of practice. The older adult with stage I pressure ulcers who needs to be turned every 2 hours could be cared for by a nursing assistant.
42
Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN?
Administer an antihistamine to a client who is describing pruritus
RATIONALE: LPN/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects.
Developing care plans and client assessment requires more critical judgment and education and should be done by an RN. Providing client instruction is a more complex skill that is included in the RN scope of practice.
43
An older, immobile client has slipped to the bottom of the bed. What does the nurse do first?
Get help and lift the client
RATIONALE: The first action by the nurse would be to get help and gently lift the client with a sheet.
Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority.
44
During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response?
Reddish blue area on the calf
RATIONALE: A reddish blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention.
Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Erythema is expected at the incision site and does not warrant an urgent response.
45
While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include?
“Administration of local anesthetic agents may cause burning.”
RATIONALE: The nurse needs to tell the client having an excisional biopsy that local anesthetic agents may cause a burning sensation.
Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy, and may be an indication of infection.
46
The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client?
Body image counseling
RATIONALE: Damage to the epidermis (the outer layer of the skin) can cause body image disturbance for clients. The nurse needs to include body image counseling when discussing this topic with the client.
Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.
47
The nurse is teaching a client who has loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client’s teaching plan?
Lift hips off the chair at least every hour
RATIONALE: The daily prevention strategy the nurse includes in the client’s teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers.
Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.
48
During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first?
Clean and dry the client’s skin
RATIONALE: Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection.
Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.
49
An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for?
Pressure ulcer development
RATIONALE: This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden.
Anemia and weight gain have no correlation with this client’s protein deficiency. The client does not have an indicated wound.
50
A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother?
“Keep the site covered with a bandage.”
RATIONALE: Keeping the site covered with a bandage prevents spread of the infection.
Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.
51
The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy?
Hyperbaric oxygen
RATIONALE: Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.
Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically debrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.
52
The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration?
Serum albumin
RATIONALE: Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.
Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.
53
Which statement by a client with psoriasis indicates that teaching about the condition has been effective?
“I should practice good handwashing technique.”
RATIONALE: Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection.
Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.
54
The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order.
2. Select injection port of intravenous (IV) tubing closes to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy.
5. Clean injection port with antiseptic swap. Allow to dry
4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port.
6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.
1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration.
3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.
55
You are working in a health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly (IM) to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of this information, you plan which of the following when administering this medication? (Select all that apply.)
- Administer the medication in the ventral gluteal site
- Use the z-track method when administering the medication
- Ask the patient questions about her major and which classes she is taking during the injection to provide distraction
56
A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.)
- The loss of his work role
- How the wife expects household tasks to be divided in the home in retirement
RATIONALE: The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time nor is the age of the patient
57
A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse’s next step is to:
Ask the son to step out of the room so she can complete her assessment
RATIONALE: The assessment leads you to suspect elder mistreatment, but the nurse needs more information directly from the patient before calling social services or the adult protective services. She will best get this information by asking the son to leave so she can ask the patient direct questions privately. If the son refuses to leave, this will be another indication that elder mistreatment may be occurring. Cognitive testing will be important but is not the priority.
58
he nurse is completing an admission assessment with an 80-yearold man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife’s death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect?
Alcohol abuse
RATIONALE: Hallmarks of alcohol abuse include frequent falling, self-neglect, and poor nutrition, which could result in weight loss and may accompany depression and loss
59
A patient’s family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.)
- Adequate staffing is available on all shifts
- Social activities are available for all residents
- Staff encourage family involvement in care planning and assisting with physical care
RATIONALE: Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person’s home rather than a hospital.
60
During a home health visit a nurse talks with a patient and his family caregiver about the patient’s medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.)
- Taking a total of eight different medications during the day
- Patient’s health history of renal disease
RATIONALE: The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.
61
What is the fastest growing subgroup of older adults?
Old old
62
An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, “I am of no use to anyone. I just want to die.” What therapy does the nurse expect the provider to order to ensure this client’s safety?
Using a selective serotonin reuptake inhibitor to manage depression
RATIONALE: Older adults have a high suicide rate, especially Euro-Caucasian men between 75 and 85 years of age. Any suicidal tendencies should be reported to the health care provider to assess the need for selective serotonin reuptake inhibitors and risk to the client.
Tricyclic antidepressants are not safe for older clients. Encouraging the client to rest and asking for a social work consultation to evaluate the client’s family situation do not address the safety issue at hand.
63
3. A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)?
Monitor blood pressure and pulse
RATIONALE: The best nursing task for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An experienced UAP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.
Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.
64
The RN has received report about four clients. Which client needs the most immediate assessment?
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
RATIONALE: The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.
The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.
65
The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize?
Ensure the client does not smoke for 6 hours before the test
RATIONALE: The essential nursing intervention for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.
Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.
66
The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse?
Inability to state name and date of birth
RATIONALE: The nurse would further assess the client who is unable to state name and date of birth. The older adult has a higher risk for hypoxemia than a younger client. The older adult can become confused during acute respiratory conditions, which requires additional investigation.
Progressive Kyphoscoliosis occurs with aging because the thorax becomes shorter. With aging, laryngeal muscles lose elasticity, and airways lose cartilage causing the client’s voice to become soft and difficult to understand. This is due to age-related changes in chest wall compliance and elasticity. Increased need for rest periods during exercise may occur.
67
When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first?
Schedule an immediate chest x-ray
RATIONALE: After thoracentesis, the nurse first makes sure a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side).
Coughing and deep breathing is done to promote lung expansion as part of the treatment for the underlying disorder. This can wait until a chest x-ray is completed. The volume of fluid will be recorded in the medical record, after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail drain catheters may be left in place to a waterseal drainage system, rather than performing thoracentesis aspiration on a recurring basis, but this action is not standard.
68
The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend?
Continuous capnography
RATIONALE: For early detection of opioid-induced respiratory depression, the nurse recommends continuous capnography. Capnography detects exhaled carbon dioxide which increases during opioid-induced respiratory depression.
Capnography, to detect opioid-induced respiratory depression, has been proven to be superior for early detection of respiratory changes and is a more sensitive indicator of respiratory depression than pulse oximetry. Arterial blood gas measurement is painful and expensive, and is not practical to use this methodology on a continuous basis. Apnea monitoring will detect a lack of breathing, but capnography will alert the nurse to respiratory depression prior to that time.
69
The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse?
Client who is speaking in three-word sentences and has an SpO2 of 90%
RATIONALE: The client that requires first and immediate evaluation by the nurse is the client who is speaking in three-word sentences and displaying dyspnea. This, coupled with an SpO2 of 90%, indicates hypoxemia.
The client displaying shortness of breath after walking up two flights of stairs may be displaying signs/symptoms of underlying cardiopulmonary disease. This is not an emergency as there is no indication of dyspnea at rest. Induration, not redness, reflects a positive Mantoux test with possible TB. This develops slowly and will not take priority over airway and breathing. Sore throat and fever are symptoms of infection that require further evaluation, but not emergently.
70
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan?
“Are you allergic to iodine or shellfish?”
RATIONALE: While preparing the client for a CT scan, the nurse’s primary assessment would be to determine whether the client has any sensitivity to the contrast material by asking if the client has a known allergy to contrast, iodine or shellfish. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.
Assessing for any metal in the body is done when clients undergo MRI. Diabetes is not a contraindication for CT with contrast. However, if the client receives metformin, the drug is stopped at least 24 hours before contrast dye is used and withheld until adequate kidney function is confirmed. Assessing regular alcohol intake is important, but is not the primary assessment.
71
The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? (Select all that apply.)
- Sensation of air hunger
- Tracheal deviation
- Blue discoloration of the lips
RATIONALE: The nurse would assess for a pneumothorax if the client has a sensation of air hunger, tracheal deviation, and blue discoloration of the lips. All clients need to be taught to go to the ED for symptoms of a pneumothorax after a thoracentesis. Symptoms include pain on the affected side, rapid heart rate, rapid, shallow respirations, sensation of air hunger, prominence of the affected side that does not move in and out with respiratory effort, tracheal deviation to the unaffected, new onset of “nagging” cough and cyanosis.
Tachycardia, rather than bradycardia, is consistent with a pneumothorax. Pain occurs on the affected side, not the unaffected side.
72
22. The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? (Select all that apply.)
- Bakers
- Coal miners
- Furniture Refinishers
- Potters
RATIONALE: The groups the nurse targets as people at risk for pulmonary disorders include bakers, coal miners, furniture refinishers, and potters. Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk for developing pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents, etc.), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.
Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.
73
The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action?
Raise the head of the bed to 60 degrees or higher
RATIONALE: Raising the head of the bed will bring the diaphragm down and allow for better chest expansion thus improving oxygenation.
74
Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
Record the amount and continue to monitor drainage
RATIONALE: Dark red drainage after surgery (50-200 ml per hour in first 3 hours) is expected but be aware of sudden increases greater than 100 ml per hour after the first three hours especially if becomes bright red in color.
75
The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is:
Arterial oxygen tension (PaO2) of 95 mmHg
RATIONALE: A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg.
76
What is the correct sequence for suctioning a patient?
4. Verify functioning of suction device and pressure
6. Increase supplemental oxygen
1. Open kit and basin
3. Lubricate catheter
2. Apply gloves
5. Connect suctioning tubing to suction catheter
8. Suction airway
7. Reapply oxygen
RATIONALE: These steps allow for smooth completion of procedure while helping to maintain patient's level of oxygenation.
77
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply).
- Sharp pleuritic pain that worsens on inspiration
- Worsening dyspnea
- Absent lung sounds to auscultation on affected side
RATIONALE: When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.
78
The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient’s health care provider? (Select all that apply.)
- SpO2 levels
- Amount, color and consistency of sputum production
- Change in respiratory rate and pattern
RATIONALE: These are key respiratory assessments that provide data on patient’s worsening respiratory status. While fluid status does impact respiratory status, it is not a priority assessment at this time. Pain in lower leg is assessed later.
79
Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.)
- Oropharyngeal suctioning of a stable patient
- Permanent tracheostomy tube suctioning
RATIONALE: Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.
80
The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find?
Increased vocal fremitus on palpation
RATIONALE: A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
81
The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient?
Positioning patient with “good lung” down
RATIONALE: Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
82
The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient?
Mucociliary clearance
RATIONALE: Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.
83
11. The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that “something is wrong.” Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action?
Sit the patient up in bed as tolerated and apply oxygen
RATIONALE: The patient’s clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient’s respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.
84
The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required?
“I need to be isolated from my family and friends so they won’t get it.”
RATIONALE: The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.
85
A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis?
Oral antibiotics will be used until there is evidence of improvement
RATIONALE: IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing are done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.
86
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions?
Chest tube with a loose-fitting dressing
RATIONALE: If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
87
A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient?
Bronchiolitis obliterans (BOS)
RATIONALE: BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.
88
An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic?
Sudden onset of confusion
RATIONALE: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.
89
The nurse is caring for a group of patients. Which patient is at risk of aspiration?
A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
RATIONALE: Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.
90
A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately?
Cover the chest wound with a nonporous dressing taped on three sides
RATIONALE: The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.
91
The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions?
“The medicine will be prescribed for 10 days.”
RATIONALE: Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.
92
The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance? (select all that apply.)
- Maintain adequate fluid intake
- Splint the chest when coughing
- Instruct patient to cough at end of exhalation
RATIONALE: Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler’s) with head slightly flexed.
93
The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis? (select all that apply.)
- A temperature of 101.4°F
- Heart rate of 120 beats/min
- A productive cough with yellow sputum
RATIONALE: A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.
94
During admission of a patient diagnosed with non–small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer? (select all that apply.)
- Asbestos exposure
- Exposure to uranium
- History of cigarette smoking
RATIONALE: Non–small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.
95
26. The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess? (select all that apply.)
- Obesity
- Malignancy
- Cigarettes smoking
- Prolonged air travel
RATIONALE: An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.
96
Common issues among community-dwelling older adults:
- decreased nutrition & hydration
- decreased mobility
- stress & loss
- accidents: falls, driving
- drug use & misuse: polypharmacy
- mental health/cognition problems (including substance abuse)
- dementia
- delirium
- alcohol use & abuse
97
Common issues among hospitalized older adults:
- sleep disorders
- nutrition
- continence
- acute & chronic confusion
- falls
- skin breakdowns
98
Ageism
- discrimination against older adults
- don't stereotype
- avoid "elder speak"
- optimize opportunities to engage older adults to participate in their care & health care decision-making including those who have impaired cognition
99
Neurologic/Sensory changes in older adults:
- loss of axons and neurons (reflexes slower)
- slowing of coordinated movements
- decreased sensations (vibrations and proprioception - sense of body position) --> implications for safety
100
Vision changes in older adults:
- decreased ability to focus & deal w/glare & nighttime vision
- can be an issue of safety when navigating
101
Hearing changes in older adults:
- high frequency hearing loss (presbycusis) - may need to communicate in very clear way
- thickening of tympanic membrane
- sclerosis of inner ear
- buildup of ear wax
102
Taste changes in older adults:
diminished
103
Integumentary changes in older adults:
- more prone to injury, don't heal as quickly
- loss of collagen fibers & decrease in glandular fxns
- decreased moisture & thinning of the dermis
- increased skin lesions & "age spots"
104
Thorax & Lung changes in older adults:
- decreased respiratory muscle strength
- anteroposterior diameter increases (barrel chest, seen in COPD)
- increased incidence of kyphosis (hunchback - limits thoracic space so lungs can't expand fully)
- drier mucous membranes - pt could have injury in mucous membrane; if giving O2, O2 can be drying
105
Heart & Cardiovascular changes in older adults:
- decreased cardiac contractile strength
- decreased baroreceptor sensitivity (responds to changes in pressure)
- decreased arterial compliance - can become hypertensive
- can develop lightheadedness
106
Gastrointestinal & Abdomen changes in older adults:
- increased amount of fatty tissues in the trunk
- slowing of peristalsis
- altered gastric & intestinal secretions
- decreased liver fxns --> risk for liver disorders & difficulty metabolizing medications
107
Urinary changes in older adults:
- decrease in # of neurons
- hypertrophy of the prostate
- increased incidence of stress incontinence in older women (dehydration, sleep disruption)
108
Musculoskeletal changes in older adults:
- muscle mass is lost, declines rapidly if not used
| - increased incidence of bone tissues related to aging & osteoporosis
109
Most frequently diagnosed conditions in older adults:
- arthritis
- hypertension
- heart disease
- cancer
110
Chronic diseases can:
- reduce quality of life
- limit activity
- require assistance
- increase healthcare costs
- increase hospitalizations
- impact emotional health
111
Common HEALTH issues among community-dwelling older adults:
- poor nutrition
- impaired mobility - makes it difficult to eat
- stress & loss - precursor to dementia
- the 3 Ds: depression, dementia, delirium
THESE ARE ALL RELATED
112
Hospitalization w/older adults associated with:
- polypharmacy: increased use of meds, adverse drug events
- iatrogenesis: complications that arise from invasive procedures (catheters), increased length of stay, nosocomial infections
- psychological decompensation: 20% of hospitalized older adults develop delirium
- poor outcomes: fxnl decline, fall-related injury, nutritional & skin problems
113
Fulmer's SPICES
```
Sleep Disorders
Problems w/eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
```
114
Katz Index of Independence in ADL (activities of daily living)
- assesses older adult's performance in the following 6 fxns:
1. Bathing
2. Dressing
3. Toileting
4. Transferring
5. Continence
6. Feeding
115
Frailty Syndrome
A geriatric syndrome w/unintentional weight loss, weakness, exhaustion, slowed physical activity
116
Nursing Process
1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation
- the whole time thinking about knowledge, standards, attitudes, experiences
117
What is Dementia?
chronic, progressive cognitive decline
118
Onset of Dementia
slow
119
Duration of Dementia
months - years
120
Cause of Dementia
unknown, possibly familial, chemical
121
Reversibility of Dementia
irreversible
122
Management of Dementia
treat signs & symptoms
123
Nursing interventions for Dementia
- reorientation not effective in late stages
- use validation therapy
- provide a safe environment
- observe for associated behaviors such as delusions or hallucinations
124
What is Delirium?
acute confused state
125
Onset of Delirium
fast
126
Duration of Delirium
hours - less than 1 month
127
Cause of Delirium
multiple, such as surgery, infection, drugs
128
Reversibility of Delirium
usually reversible
129
Management of Delirium
remove or treat the cause
130
Nursing interventions of Delirium
- reorient the patient to reality
| - provide a safe environment
131
Leading indicator of quality & safety in the hospital
falls (lack of)
132
Leading cause of death from injury for adults older than 65
falls
133
What are falls considered?
"geriatric syndrome"
134
Intrinsic risk factors for falls (what is going on w/patient)
- older age
- history of falls
- depression
- muscle weakness
135
Extrinsic/Environmental risk factors for falls
- polypharmacy
- loose carpets
- canes/wheelchairs
- inadequate lighting
136
How do falls come to the attention of the healthcare team?
- medical history
- physical assessment
- mental status
- labs & diagnostic results
- home safety assessment - minimal clutter & adequate lighting
137
Common causes of Delirium
```
Drugs
Elimination
Liver & other organs
Infection (UTI)
Respiratory infections (not enough O2)
Injury
Unfamiliar environment
Metabolic
```
