Unit 12 NR328 Tonsillitis Case Study Actual Questions and Correct
Answers
Q1
Select the 4 findings that require immediate attention
Answer: Compromised airwayWeight down from admission weight History of increasing difficulty
eating
Morphine several times during the night
Q2
After the nurse's initial assessment, the client is at highest risk for developing asevidenced by the
client's
Answer: ineffective airway clearance, inflammation and secretions
Q3
For each potential nursing intervention,click to specify whether the intervention is indicated,
nonessential, or contraindicated. Mark only one response per intervention
Answer: Indicated -Place client in high Fowler's position. Suction secretions.Nonessential -
Request an order to
insert an additional peripheral venous access device (VAD).Contraindicated -Give 3 mg of IV
morphine.Prepare the client for defibrillation
Q4
Select the 3 orders that the nurse should perform right away
Answer: Acetaminophen-hydrocodone 33.3 mg-0.5 mg every 4 hours as needed (PRN) for severe
painLaboratory
test: complete blood count (CBC), basic metabolic panel (BMP), arterial blood gas (ABGs)Oxygen
via
nasal cannula to maintain pulse oximetry at 94% or greater
Q5
For each assessment finding, click to specify if the finding indicates that the client's condition has
improved, has not changed, or has declined
Answer: Improved - P 88 Pain levelPulse oximetry 100%No change - Breath sounds, RR 24
Declined - NONE
Answers
Q1
Select the 4 findings that require immediate attention
Answer: Compromised airwayWeight down from admission weight History of increasing difficulty
eating
Morphine several times during the night
Q2
After the nurse's initial assessment, the client is at highest risk for developing asevidenced by the
client's
Answer: ineffective airway clearance, inflammation and secretions
Q3
For each potential nursing intervention,click to specify whether the intervention is indicated,
nonessential, or contraindicated. Mark only one response per intervention
Answer: Indicated -Place client in high Fowler's position. Suction secretions.Nonessential -
Request an order to
insert an additional peripheral venous access device (VAD).Contraindicated -Give 3 mg of IV
morphine.Prepare the client for defibrillation
Q4
Select the 3 orders that the nurse should perform right away
Answer: Acetaminophen-hydrocodone 33.3 mg-0.5 mg every 4 hours as needed (PRN) for severe
painLaboratory
test: complete blood count (CBC), basic metabolic panel (BMP), arterial blood gas (ABGs)Oxygen
via
nasal cannula to maintain pulse oximetry at 94% or greater
Q5
For each assessment finding, click to specify if the finding indicates that the client's condition has
improved, has not changed, or has declined
Answer: Improved - P 88 Pain levelPulse oximetry 100%No change - Breath sounds, RR 24
Declined - NONE
