LEWIS - EXAM 3 - MISC. ACCURATE QUESTIONS AND ANSWERS WITH SOLUTIONS 2024

LEWIS - EXAM 3 - MISC. ACCURATE QUESTIONS AN D ANSWERS WITH SOLUTIONS 2024 ANS: B With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side -lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decreas e the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. - ANSWER Which action should the nurse plan to prevent as piration in a high -risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side -lying position. c. Insert a nasogastric tube for feeding a patient with high calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed. ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contracep tives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting. - ANSWER The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?" ANS: A Hypercalcemia may lead to complications s uch as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening. - ANSWER Which information obtained by the nurse assessing a patient admitted wi th multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence -Jones protein. d. Patient is complaining of severe back pain. ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessm ents or interventions, but they are not at immediate risk for life -threatening complications. - ANSWER After change -of-shift report, which patient should the nurse assess first? a. A 19 -yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%