PATIENT CARE SYNTHESIS AND COMPLEX
CASE MANAGEMENT
◉ A nurse is reviewing ECG strips for several clients. Which of the
following images should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and
irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to
originate somewhere other than the ventricles. Rate between 100-
280/min
D. a P wave for every QRS, rate is 60-100/min.
Answer: A.) multiple irregular and variable waves at the baseline
and irregular R to R intervals
,◉ A nurse is preparing to admit a client who has a new
tracheostomy from the operating room. Which of the following items
is the priority for the nurse to have available in the client's room
upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula.
Answer: A.) Obturator
The obturator can be inserted in the stoma in the even of
dislodgment or decannulation to maintain an airway until a new
trach tube can be placed. For the first 72 hr following the insertion
of a trach, dislodgement or decannulation is considered an
emergency
◉ A nurse is caring for a client who had a below the knee
amputation due to a traumatic injury 2 days ago. Which of the
following statements should the nurse use to assess how the client is
coping with this change in their body image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to make when
doing your job"
,C. "Let's discuss how you can adjust once you have a prosthesis"
D. "What are some possible issues that you foresee when completing
self-management tasks".
Answer: A .) "Tell me how the changes to your leg make you feel"
◉ A nurse in an endoscopy clinic is providing teaching to a client
who is to undergo a colonoscopy for colon cancer screening. Which
of the following information should the nurse provide
A. "You should have nothing to eat or drink for 3 hours prior to the
procedure"
B. "You should drink the bowel preparation slowly to prevent
nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure".
Answer: D.) "You will need someone to drive you home after your
procedure"
Do not drive for 12-18 hours following the procedure, because
during a colonoscopy, the pt receives moderate sedation
◉ A nurse is monitoring a client who is receiving moderate sedation
with midazolam. Which of the following findings requires immediate
intervention by the nurse
, A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea.
Answer: B) No response to verbal stimuli
using urgent vs non-urgent approach, this is the priority. During
moderate sedation, the pt should be able to provide a response to
questions and commands. No response to verbal stimuli can indicate
a loss or consciousness or oversedation
◉ A nurse is reviewing the laboratory findings for a client who has
heart failure and is taking furosemide. The nurse should identify
which of the following findings as an adverse effect of the
medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia.
Answer: C. Potassium 3.2 mEq/L
Loop diuretics remove excessive extracellular fluid through the
kidneys, causing an increased excretion of potassium. Monitor for
dysrhythmias