Medical Surgical Nursing Final 2023 Update A+

A nurse is caring for a patient receiving a transfusion and assesses that the patient is wheezing and it's complaining of back pain. What nursing action should take place after stopping the transfusion? - ANS-Notify the charge nurse Signs that you need to suction a patient with a tracheostomy - ANS-Pt becomes restless and has an increase in vital signs A nurse is completing an initial assessment on a new patient being seen in a hospital clinic. The presentation of this female patient includes symptoms of tiredness and large areas of ecchymosis. Which question is most important for the nurse to ask? - ANS-Do your gums bleed easily What is the sympathetic pain response? - ANS-Increased pulse, BP, RR, dilated pupils, perspiration and pallor what are the s/s of organ dysfunction? - ANS-dry mouth, thirst, sluggish pupils, peripheral edema, muscle weakness, mental status changes, hypotension, weak and thready pulses, increased RR, decreased urine output, cyanosis What are the types of pain? - ANS-Acute, chronic, referred and cancer related What assessment made by a nurse indicates that respiratory arrest is imminent? - ANSAbsence of breathing sounds At 10 AM and I was received two units of blood for the patient to be transfused. What is the most appropriate nursing action? - ANS-Set up one unit for the transition to start by 10:30 and send the other unit back until the first one has infused What happens to the sickle shaped red blood cells during sickle cell crisis? - ANSobstruction of major arteries Priority nursing diagnosis for shock - ANS-Inadequate cardiac output and risk for impaired cardiovascular function What information should A nurse be sure to include on preparing discharge plans for a patient recently diagnosed with pernicious anemia? - ANS-providing sufficient rest periods throughout the day What is the rationale for administering injections of vitamin B 12 to patients with pernicious anemia? - ANS-The patient may lack the intrinsic factor necessary for vitamin B 12 absorption Types of distributive shock? - ANS-anaphylactic, septic, neurogenic What does hydroxyurea do? - ANS-Produce hemoglobin that resist sickling Patho for distributive shock - ANS-excessive dilation of blood vessels or decreased vascular resistance causing the blood to be improperly distributed A patient with polycythemia vera will have what lab value elevated? - ANS-High Hgb level a nurse is caring for a patient with crushing injuries from an automobile accident and the patient is bleeding profusely from the nose, mouth, rectum, as well as from the other injuries. What should the nurse suspect as the cause of the patient's bleeding? - ANSDisseminated intravascular coagulation (DIC) What is responsible for initiating the inflammatory response in addition to the immunoglobulin E (IgE)? - ANS-Basophils Complication of distributive shock - ANS-increased capillary permeability which permits plasma to leak into the interstitial compartments → decreasing intravascular blood volume What is true concerning passive-acquired immunity? - ANS-Antibodies are acquired from the outside the host and instilled in the host. After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and radiation and has the potential for injury. Which nursing assessment should cause the nurse concern? - ANS-Increasing abdominal girth What is the primary function in the immune response? - ANS-Filter microorganisms from the blood What laboratory result is monitored in a patient with leukemia? - ANS-Platelet count Causes of neurogenic shock - ANS-spinal cord injury (T4), regional anesthesia, disease of the upper spinal cord, certain depressant drugs, adrenal insufficiency. What are normal age-related changes of the respiratory system? - ANS-smell is not as accurate, dry nose, occasional nose bleeds Causes of hypotension with cervical spine injury - ANS-This is because of the loss of nervous system control which works to keep the blood pressure stable, as well as loss of muscle tone which helps to return blood to the heart. A patient comes into the clinic complaining of a runny nose and facial pain. What should the nurse's initial assessment include? - ANS-Assessment for nasal drainage and sinus tenderness what are the signs and symptoms of speed shock? - ANS-light-headedness, tightness in the chest, flushed face, irregular pulse How to prevent immobility issues - ANS-rotational bed therapy, careful positioning active and passive exercises What is a sign that drug protocols are not effective with acute leukemia? - ANS-Platelet count lower than 50,000/mm3 s/s fluid volume excess - ANS-rising bp, bounding pulse, rapid respiratory, decreased temp & edema. What should the nurse anticipate that a positive blood analysis would show for a patient diagnosed with HIV? - ANS-High levels of HIV-infected cells s/s of infiltration - ANS-pain, burning sensation, pale, puffy, hard & cool. How long does the initial stage of HIV infection usually last? - ANS-4 to 8 weeks s/s of phlebitis - ANS-redness, swelling, warmth & tenderness. When taking retrovir what should the nurse be especially observant for? - ANSJaundice How to encourage urination - ANS-Placing hand in water, warm water poured over perineum, blowing bubbles through a straw, sitting on the toilet, straight cath What is important for an immunocompromised patient who is also diagnosed with microsporidiosis? - ANS-Drink 3 quarts of fluid per day to combat dehydration. What are complications of cardiac cath? - ANS-bleeding, hematoma formation, infection, dye-induced allergic reactions (seafood/iodine), high exposure of radiation & embolus/thrombus formation at the insertion site What indicates a patient has entered the third stage of HIV infection? - ANS-T-helper CD4 cell count of 500 Interventions for cirrhosis of the liver - ANS-encourage the patient to eat even if the patient isn't hungry, arrange a dietary consult and report likes and dislikes, schedule nursing care to encourage undisturbed rest, TCDB, relieve pruritus w. gentle bathing with mild soap & tepid water, thorough rinsing and moisturizing, elevate the HOB to promote breathing, handle pt gently...