Nur 265 Literally Exam 3. (Answered) Complete Solution

Nur 265 Literally Exam 3. (Answered) Complete Solution #1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the primary healthcare provider (PHCP) in the client: Takes prescribed warfarin daily. RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of blood) #2: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if performed by the newly hired nurse, requires intervention by the charge nurse? Raising the foot of the client’s bed. RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP. #3: The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed Clustering client care activities RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic elevation. #4: The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should the nurse identify as being at greatest risk? 20 year old college student who participates on the football team. RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury. #5: The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? The development of asymmetric pupils with no reaction to light in the client who has a TBI. RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non reactive pupils. #6: The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the nurse take next? Perform a halo sign test. RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed for glucose and electrolyte content. Place on a white absorbent paper or linen. #7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a MVA. Which of the following statements, if made by the partners would indicated the need for additional teaching? I will bring my partner to the ED if they immediately starting vomiting. RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected. #8: The nurse is caring for the following assigned clients. Which client should the nurse see first? The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg. RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia. #9: The nurse is caring for a client who is 24 hours post op following a craniotomy. The client is reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the following actions should the nurse take? Perform a neurological test. RATIONALE: Pg. 2430. Symptoms of increased ICP included servers headache, deteriorating LOC, restlessness, and irritability. #10: The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the client Has a change in BP from 120/78 to 130/60 mm Hg. RATIONALE: Pg. 2256. Changes in VS that require immediate notification to the HCP are a widened pulse pressure, new bradycardia, and irregular respiratory effort. #11: The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which of the following actions should the nurse take first? Prepare the client for a lumbar puncture. RATIONALE: Pg. 2251. Most significant lab test to determine BM is testing of CSF with a lumbar puncture. A broad spectrum antibiotic is given before the lumbar puncture. #12: The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a history of HIV. Which of the following actions should the nurse take first? Implement seizure precautions. RATIONALE: This patient could have encephalitis due to the hx of HIV and fever. Seizure activity is common. #13: Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95, HR 68, O2 95%. Which of the following actions should the nurse take? Palpate the patient’s bladder. RATIONALE: Catheterize the patient with autonomic dysreflexia to decrease the pressure. This is an emergency. Immediately elevated the HOB. #14: The nurse working in the ED is caring for a client admitted with a suspected spinal cord injury. It would require follow up by the nurse if the PHCP prescribed which of the following? Mannitol. RATIONALE: Pg. 2291. Mannitol is used to treat ICP. Dextran, Atropine sulfate, and Dopamine are used to treat SCI. #15: The nurse has taught a client who has myasthenia gravis about taking their prescribed medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which of the following is an appropriate response by the nurse? This allows the medication to have maximum effect, so it is easier for you to chew and swallow. RATIONALE: Pg. 2344. Drug Alert! Eat 45-60 mins prior to avoid aspiration. #16: The nurse is working in the ED is caring for a client who has MG. The client presents with muscle weakness, NVD, and pulse of 58. Which of the following medications should the nurse admin immediately? Atropine sulfate. RATIONALE: Pg. 2345. In cholinergic crisis, admin Atropine I mg IV. #17: The nurse preceptor is observing a newly hired nurse care for a client who has MG. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? Preparing to admin a prescribed PRN laxative. RATIONALE: Pg. 2346. Perform tasks during peak medication times, monitor serum albumin levels, and provide high calorie snacks. #18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the following statements by the client would indicate need for further teaching? I will tape my affected eye closed at bedtime. RATIONALE: Pg. 2354. Seizure medication is first choice drug, facial twitching or spasms may occur, pain is usually provoked by minimal stimulation of a trigger zone (such as denture procedures.) Taping of the eye is not necessary for this patient. #19: The nurse is provided teaching to a client who was just diagnosed with Bell’s palsy. Which of the following client statements requires follow up by the nurse? I will need to take carbamazepine to control my symptoms. RATIONALE: Pg. 2255. This medication is used to treat TN. Patients will take steroids, use heat to control pain, and may experience ringing of the ears. #20: The nurse is caring for the following assigned clients. It would be appropriate for the nurse to recommend a referral for evaluation for palliative care for the client who Has had ALS for the past 3 years and was recently admitted with pain, fatigue, and difficulty breathing. RATIONALE: Pg. 2268. ALS is a chronic neurological disease that causes progressive muscle weakness and wasting, leading to paralysis of respiratory muscles. #21: The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse “I don’t want to be put on a breathing machine.” Which of the following is an appropriate response by the nurse? What would you like to be done if you start to have difficulty breathing? RATIONALE: Involve the client in their care, ask what they’d like to happen. #22: The nurse has attended a CE conference on GB. Which of the following statements by the nurse indicates a correct understanding of the conference? The immune system reacts by destroying the myelin sheath. RATIONALE: Pg. 2329. Primarily the axons are affected. In other forms, demyelination typically begin in the legs and spread to the arms and upper body. #23: The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations of 8 and shallow, and a pulse ox of 88%. Which of the following actions should the nurse take? Prepare the client for intubation. RATIONALE: PG. 2334. The priority nursing intervention of airway management is to promote airway latency and adequate gas exchange. #24: The nurse is using the rule of 9s to calculate the extent of a clients burn injury. The client has burns to the posterior area of the torso, arms, and legs. The nurse should document that the percent of the body surface burned is: 45% 18 + 4.5 + 4.5 + 9 + 9 = 45 RATIONALE: Pg. 1302. Rule of 9s for estimating burn percentage. Head A&P: 4.5%, 4.5% Arms A&P: 4.5%, 4.5% Torso A&P: 18%, 18% Genitals: 1% Legs A&P: 9%, 9% #25: The nurse is caring for a male client who sustained full thickness burns on the back and posterior legs six hours ago. Which of the following lab values would be an initial expected finding? A serum sodium level of 128. RATIONALE: Pg. 1286. Imbalances include hyperkalemia and hyponatremia. #26: The nurse is caring for a client who is burned and has developed drooling and difficulty swallowing. Which of the following actions should the nurse first take? Auscultate breath sounds over the trachea and mainstream bronchi. RATIONALE: Pg. 1298. Upper airway edema and inhalation injury are most common in the trachea and mainstream bronchi. Auscultation of these areas may reveal wheezes, which indicate partial obstruction. #27: The nurse is caring for a client who sustained an electrical injury and was brought to the ED. Which of the following nursing actions should the nurse take first? Place the client on continuous cardiac monitoring RATIONALE: Pg. 1295. Electrical burns; obtain an ECG. #28: The nurse is caring for a client who suffered 33% TBSA 48hr ago. The nurse notes a gradual increase in the client’s urine output over the last 12 hrs. Which of the following actions would the nurse take? Document the findings and continue to monitor the output. RATIONALE: Pg. 1301. Urine output is decreased during the first 24 hr of the resuscitation phase. Monitor hourly output. #29: The nurse working in the ED is caring for a client with full thickness burns to 25% of the TSBA. After ensuring cardiopulmonary stability, which of the following actions should the nurse take next? Consult with the dietician regarding nutritional needs for the client. RATIONALE: Pg. 1326. Coordinate with the registered dietitian to meet the expected outcomes regarding the patient’s nutritional status. #30: The nurse working in the burn unit is caring for a client who suffered burn injuries 48 hrs ago and has been receiving resuscitation. The client has been stable but is now experiencing a change in respiratory status. Which of the following should the nurse correlate to this change in the client’s status? This is a delayed onset respiratory complication due to fluid resuscitation. RATIONALE: Pg. 1300. Monitor patient’s respiratory efforts closely to recognize development of pulmonary edema. #31: The nurse preceptor is observing a newly hired nurse who is caring for assigned clients in a burn unit. It would require follow up by the preceptor if the newly hired nurse: Applies an enzymatic debridement agent to black eschar tissue. RATIONALE: Pg. 1318. Enzymatic debridement is seldom used alone in larger burns bc it is slow and prolongs the hospital stay, increasing the risk for infection. #32: The nurse has taught a client with facial burns about wearing the facial pressure garment. Which of the following client statements indicates understanding of the teaching? My scars should be less severe with the use of the mask. RATIONALE: Pg. 1328. Reinforce to the patient and family that wearing pressure garments is beneficial in saving mobility and reducing scarring. #33: The nurse working on the burn step down unit has become aware of the following situations. The nurse should initially follow up with the client who has: Increased burn wound drainage that has developed an odor. RATIONALE: This is a s/s of an infection. #34: The nurse is admitting a client who has sustained a therm burn injury. The nurse notes the following assessment findings. HR 140, RR 25, BP 70/40, Skin pale, faint pedal pulses. Which of the following actions should the nurse take first? Initiate prescribed IV fluid resuscitation. RATIONALE: Pg. 1294. General management of all burns includes initiating an IV line and begin fluid replacement. #35: The nurse is caring for a client who has circumferential full thickness burns to the left lower extremity. Which of the following findings of the affected extremity requires immediate follow up by the nurse? Numbness and tingling of the foot. RATIONALE: Circulation issue. Edema can impair perfusion. #36: The nursing is caring for a client who was admitted 12 hr ago with severe burns. The client is receiving fluid resuscitation and weighs 175 lbs (79.5 kg). Which assessment findings is a priority for the nurse to report to PHCP? Urine output of 30 mL/hr, Potassium level 6.2, dyspnea with stridor. RATIONALE: Pg. 1286. (0.5mL x 79.5 kg = 39.75 mL/hr), normal K 3.5-5. Stridor or wheezing indications #37: The nurse working the ED is assessing a client who presents with clinical manifestations of shock. Which of the following manifestations indicates that the client’s shock is caused by sepsis (infection)? Hypotension. RATIONALE: Pg. 1949. Septic shock is sepsis induced hypotension persisting despite adequate fluid resuscitation. #38: The nurse is caring for a client who is not responding to interventions for treatment of shock. Which of the following actions should the nurse include during this phase of the client’s care? Communicate clearly and frequently with the client’s family. RATIONALE: Pg. 1949. Even with appropriate intervention, the death rate among patients in this stage of sepsis is very high. #39: The nurse is admitting a client diagnosed with septic shock. Which of the following interventions should the nurse perform next? Obtain 2 sets of blood cultures. RATIONALE: Pg. 1956. Obtain blood cultures before administering antibiotics. #40: The nurse is caring for a client who has severe septic shock. Which of the following prescriptions should the nurse question? Enoxaparin 40 mg subq BID. RATIONALE: Pg. 1957. Heparin therapy with fractionated heparin is used to limit inappropriate clotting and prevent the excessive consumption of clotting factors. #41: The nurse is caring for a client who has developed hypovolemic shock due to blood loss during surgery. The nurse should place the client in with of the following positions? HOB flat with the feet elevated. RATIONALE: Pg. 1940. Best practice for patient safety and quality care in the patient with hypovolemic shock. Elevate the patient’s feet, keeping the head flat or elevated no more than a 30 degree angle. #42: The nurse is monitoring a client who is receiving dopamine infusion for treatment of hypovolemic shock. Which of the following indicates a therapeutic response to the medication? A pulse rate that has increased from 62-78. RATIONALE: Pg. 1942. Common examples of drug therapy. Dopamine increases MAP, can cause decreased urinary output, hypertension (assess BP q15 min) HTN can indicate overdose. #43: The nurse is caring for a client who has developed hypovolemic shock resulting from dehydration due to several days of VD. Which of the following actions should the nurse take next? Initiate a 0.9% sodium chloride (NaCl) infusion. RATIONALE: Pg. 1941. Crystalloid fluids help maintain an adequate fluid electrolyte balance. Two common solutions are normal saline and Ringer’s lactate. #44: The nurse should recognize the development of obstructive shock in the client who: Has developed a large pericardial effusion resulting in cardiac tamponade. RATIONALE: Pg. 1925 (bottom): Obstructive shock cause and risk factors include cardiac tamponade. #45: The nurse is caring for a client who is in cardiogenic shock and has been prescribed continuous infusion of norepinephrine. The nurse should recognize that the therapeutic effect of this medication: Increase the MAP RATIONALE: Davis drug guide. Therapeutic effects are increased BP and cardiac output. #46: The nurse is caring for a client who is in cardiogenic shock, was starting on a continuous infusion of an inotrope and has received a diuretic. It is a priority for the nurse to notify the PHCP if the client: