Final case studies 12 and 16 questions and answers well illustrated.

Final case studies 12 and 16 questions and answers well illustrated. What is the priority nursing concept to consider in planning emergency interventions for Mr. S (vomiting blood)? 1. Pain 2. Anxiety 3. Fluid and electrolyte balance 4. Adherence - correct answers.3. Fluid and electrolyte balance What are priority interventions to perform for this patient (vomiting blood, alcoholic)? Select all that apply 1. Prepare for endotracheal intubation 2. Assist with central line placement 3. Check stool for occult blood 4. Administer supplemental oxygen 5. Monitor vital signs and oxygen saturation 6. Monitor hemoglobin and hematocrit - correct answers.4. Administer supplemental oxygen 5. Monitor vital signs and oxygen saturation 6. Monitor hemoglobin and hematocrit Which task is most appropriate to delegate to the UAP? 1. Repeating measurement of vital signs 2. Gathering equipment for NG tube insertion 3. Obtaining the blood glucose level every 2 hours 4. Offering ice chips or small sips of water - correct answers.1. Repeating measurement of vital signs The HCP has ordered several immediate (STAT) interventions for Mr. S (vomiting blood). Which task would the nurse perform first? 1. Draw blood for complete blood count, and type and crossmatch 2. Establish two peripheral IV lines with 16-gauge catheters 3. Insert an NG tube and observe gastric contents 4. Repeat the vital signs and apply pulse oximeter - correct answers.2. Establish two peripheral IV lines with 16-gauge catheters The nurse is performing additional assessment and history taking for Mr. S (vomiting blood). Which finding should be immediately reported to the HCP? 1. Melena stools 2. History of nonsteroidal anti-inflammatory drug use 3. Tense and rigid abdomen 4. Risk factors for human immunodeficiency virus - correct answers.3. Tense and rigid abdomen The HCP prescribes NG tube insertion. The nurse places the patient in a high Fowler's position, provides an emesis basin, and inspects the nostrils for patency. List the correct order of actions for this procedure. 1. Measure tube from the tip of nose, to the earlobe, to the xiphoid process 2. Insert the lubricated tube into the most patent nostril 3. Ask the patient to sip water as the tube is passed 4. When tube is just above the oropharynx, instruct the patient to bend the chin forward 5. Check pH to verify to verify tube placement; obtain an order for a radiograph 1, 2, 4, 3, 5 - correct answers.1, 2, 4, 3, 5 The nurse is selecting PPE to don before inserting the NG tube. Which factors will the nurse consider before making the selection? Select all that apply 1. Facility policies for procedures 2. Likelihood of exposure to blood and body fluids 3. Patient's ability and willingness to cooperate 4. Own skill level and proficiency at procedure 5. Patient's health history and medical conditions 6. Availability of PPE at the bedside or on the unit - correct answers.1. Facility policies for procedures 2. Likelihood of exposure to blood and body fluids 3. Patient's ability and willingness to cooperate 4. Own skill level and proficiency at procedure 5. Patient's health history and medical conditions 8. Despite the nurse's best efforts at therapeutic communication, Mr. S refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose." What should the nurse do first? 1. Physically restrain him and insert the tube 2. Explain the "against medical advice" form 3. Notify the nursing supervisor and patient advocate 4. Page the HCP and document the attempt - correct answers.4. Page the HCP and document the attempt After the NG tube is inserted, which assessment finding is cause for greatest concern? 1. The patient reports that the tube is irritating the nose and throat feels sore 2. Gastric contents have a coffee-ground appearance 3. The patient demonstrates coughing and cannot speak clearly 4. Gastric fluid is bright red and has small clots - correct answers.3. The patient demonstrates coughing and cannot speak clearly The nurse is most likely to seek out which lab results to determine if there are untoward affects associated with vomiting, NG suction, or lavage? 1. WBC counts 2. Hematocrit and hemoglobin 3. Serum electrolytes 4. BUN and serum creatinine - correct answers.3. Serum electrolytes The lab informs the nurse that the phlebotomist may have mislabeled or drawn the sample for STAT blood tests from another patient, not Mr. S. What should the nurse do first? 1. Call the phlebotomist to come back 2. Draw a new blood sample and label it 3. Report the phlebotomist to her or his supervisor 4. Ask the phlebotomist to explain what happened - correct answers.2. Draw a new blood sample and label it The HCP orders a STAT blood transfusion. In the event of an emergency, a type-specific non-crossmatched blood product could be used. Which blood product could be used in this case? 1. O negative 2. AB negative 3. AB positive 4. A negative - correct answers.1. O negative The nurse is preparing to administer a blood transfusion to Mr. S. First, the nurse inspects the bag for leaks, clots, or unusual color and compares the bag label with the chart and the blood bag forms. Place the steps of transfusion in the correct order. 1. Prime the correct tubing and filter with normal saline 2. Take vital signs before starting the transfusion 3. Transfuse the first 10 mL slowly; monitor the patient closely 4. Have two nurses or HCPs compare the blood band identification with the tag on the blood bag 5. Document the outcomes, name or personnel, and starting and ending times 6. Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete - correct answers.4, 1, 2, 3, 6, 5 The nurse sees that Mr. S's (vomiting blood) INR value is 2.5. Which action should the nurse take next? 1. No action should be taken because this is an expected finding related to GI bleeding 2. HCP should be notified for possible prescription of fresh frozen plasma (FFP) 3. Lab findings should be reevaluated at completion of treatments 4. The blood bank should be contacted for additional units of packed red blood cells - correct answers.2. HCP should be notified for possible prescription of fresh frozen plasma (FFP) An L&D nurse calls the ED charge nurse and says, "I heard that Mr. S is in the ED throwing up blood. He's my ex-husband, so I looked up his medical record. How's he doing?" What should the ED charge nurse do first? 1. Invite the L&D nurse down to the ED to see Mr. S in person 2. Ask Mr. S if he wants information released to his ex-wife 3. Report the L&D nurse for violation of patient privacy 4. Explain to the L&D nurse that no information can be given out - correct answers.4. Explain to the L&D nurse that no information can be given out The nurse is talking to Mr. S about his alcohol consumption. Which statement represents the most common defense mechanism that is used by people who have problems with alcoholism? 1. You would drink, too, if you were married to my wife 2. My wife and I have a couple beers after work. It's no big deal. 3. If you think I drink a lot, you should see my wife put it away 4. I would rather talk to my wife about this situation when I get home - correct answers.2. My wife and I have a couple beers after work. It's no big deal. The nurse suspects that Mr. S may be at risk for alcohol withdrawal effects. What is an early manifestation? 1. Startles easily 2. Paranoid delusions 3. Slurred speech 4. Grand mal seizure - correct answers.1. Startles easily Which serious complications may result from alcohol withdrawal delirium. Select all that apply 1. Myocardial infarction 2. Electrolyte imbalance 3. Aspiration pneumonia 4. Anaphylaxis 5. Sepsis 6. Suicide - correct answers.1. Myocardial infarction 2. Electrolyte imbalance 3. Aspiration pneumonia 5. Sepsis 6. Suicide Mr. S and his wife ask for privacy so that they can talk. Later, when the nurse returns to check on him, the NG tube is on the floor, there is a strong odor of alcohol on Mr. S's breath, and he appears very drowsy. What should the nurse do first? 1. Politely ask the wife to leave and call security to check the room for illicit substances 2. Assess the patient's mental status and ask what happened to the NG tube 3. Explain that his behavior is unacceptable and counterproductive to his therapy 4. Reinsert an NG tube and call the HCP for an order for a STAT blood alcohol test - correct answers.2. Assess the patient's mental status and ask what happened to the NG tube Mr. S needs to be admitted to the medical-surgical unit for observation and continued management of acute gastritis with bleeding. The ED nurse is calling the receiving nurse on the medical-surgical unit. Prioritize the following information according to the SBAR format. 1. Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours 2. This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding. 3. Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an EGD 4. Mr. S is currently alert and oriented but is anxious. The last vital signs are BP 140/80, pulse 90, respirations 24, and pulse oximetry reading 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 ml/hr in each IV line. He received one unit of PRBC and one unit of FFP. He has a NG tube in the right nares. Initially, there was small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction. - correct answers.2, 1, 4, 3 The HCP recommends that Mr. S have an EGD to stop the bleeding. The nurse sees that the HCP has written on the order sheet: "Have patient sign consent form for EGD." What should the nurse do first? 1. Assess the patient's understanding of the procedure, explain the risks, and obtain the patient's signature if he appears to understand 2. Call the HCP and politely state that obtaining the patient's consent for a procedure is outside the scope of nursing practice 3. Ask the charge nurse to clarify if HCPs would typically write this type of order and, if so, how it should be handled 4. Decline to follow the order, write an incident report, and call the unit manager to report the HCP for writing an inappropriate order - correct answers.2. Call the HCP and politely state that obtaining the patient's consent for a procedure is outside the scope of nursing practice During the EGD procedure, Mr. S is given midazolam hydrochloride. What is the priority assessment related to this medication? 1. Monitor for cardiac dysrhythmias 2. Assess for adequate relief of pain 3. Monitor depth and rate of respirations 4. Assess for relief of nausea and vomiting - correct answers.3. Monitor depth and rate of respirations After the EGD procedure, Mr. S returns to the medical-surgical unit. He is drowsy but readily arouses to light stimuli. His vital signs are BP 110/74, pulse 82, respirations 20, and temperature 99. What is the priority intervention? 1. Offer cool oral fluids for sore throat 2. Raise the side rails of the bed 3. Apply a small ice ack to the periorbital area 4. Assess the presence of the gag reflex - correct answers.4. Assess the presence of the gag reflex