Complex Care Final Exam 24/25 Questions With 100% Correct Answers.

Complex Care Final Exam 24/25 Questions With 100% Correct Answers. The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Answer- c. Obtain a sputum specimen for culture and Gram stain. The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? Answer- c. "I need to be isolated from my family and friends so they won't get it." A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? Answer- c. Oral antibiotics will be used until there is evidence of improvement. The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Answer- a. Maintain adequate fluid intake. c. Splint the chest when coughing. e. Instruct patient to cough at end of exhalation. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? Answer- d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? Answer- c. Positioning patient with "good lung" down One week after a thoracotomy, a patient with chest tubes (CTs) to water- seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Answer- c. Chest tube with a loose-fitting dressing During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Answer- a. Pneumococcal While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Answer- c. Obtain a physician's order for supplemental oxygen. The nurse is caring for a group of patients. Which patient is at risk of aspiration? Answer- c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Answer- d. Bronchiolitis obliterans (BOS) The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Answer- a. Basilar crackles The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? Answer- a. A temperature of 101.4°F a. Heart rate of 120 beats/min d. A productive cough with yellow sputum The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? Answer- b. "The medicine will be prescribed for 10 days." The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Answer- d. Sit the patient up in bed as tolerated and apply oxygen. A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Answer- a. Cover the chest wound with a nonporous dressing taped on three sides. An older adult patient is admitted with acute respiratory distress related to corpulmonale. Which nursing action is most appropriate during admission of this patient? Answer- d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Answer- c. Increased vocal fremitus on palpation The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Answer- d. Increase fluid intake to 3 L/day if tolerated. An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Answer- a. Sudden onset of confusion During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? Answer- a. Asbestos exposure b. Exposure to uranium d. History of cigarette smoking The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? Answer- b. Mucociliary clearance The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? Answer- d. Less discomfort and faster return to normal activity A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? Answer- a. Antibiotic The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Answer- a. Obesity c. Malignancy d. Cigarette smoking e. Prolonged air travel After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? Answer- b. Sputum culture and sensitivity The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? Answer- d. Venous thromboembolism The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? Answer- c. Prothrombin time (PT) When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? Answer- a. Duplex ultrasound Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Answer- a. Remove the patient's IV catheter. A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? Answer- c. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)? Answer- b. Cold and mottled c. Complaints of paresthesia d. Pulse not palpable with Doppler diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? Answer- b. Smoking A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? Answer- c. Improved finger perfusion The patient has chronic venous insufficiency and a venous ulcer. 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