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Exam (elaborations)

Swift River - Med-Surg - Scenarios

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Swift River - Med-Surg - Scenarios

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Swift River - Med-Surg - Scenarios
Study online at https://quizlet.com/_fpx9hw

1. Calvin Umbyuma, a 42-year-old male, has been Maslow's Hierarchy of Needs - High
admitted for shortness of breath and pleuritic Priority
chest pain. He was diagnosed with HIV over a ABCs - High Priority
year ago. He recently traveled Kenya, to visit Safety and Risk Reduction - High Pri-
his mother, who is ill. While visiting his moth- ority
er, he received herbal therapies to help with Urgent vs Nonurgent - High Priority
the manifestations he was experiencing. Vital Chronic vs Acute/Stable vs Unstable -
signs are temperature 100.9°F (38.3° C), respi- High Priority
rations 22/min, heart rate 92/min, blood pres-
sure 152/89 mmHg, oxygen saturation 91% on
room air. Inflammatory markers including ery-
throcyte sedimentation rate (ESR) and c-reac-
tive protein (CRP) are elevated at 78.9 mmh and
67.2 mg/L. The client has been placed in a neg-
ative pressure room at the end of the hallway.

2. Calvin Umbyuma Which of the following concerns
The nurse reviews the information received should the nurse address while pro-
in the report and enters the client's room to viding client care? (Select all that ap-
perform a physical assessment. Upon assess- ply.)
ment, the client is alert and oriented to per- Correct Options:
son, place, time, and event. Pupils are equal, Physiological: Comfort
round, reactive to light, and accommodation. Health Promotion: Education
Lung sounds reveal crackles in right upper Physiological: Immunity
lobe. Client is expectorating blood-tinged mu- Physiological: Infection
copurulent sputum and reports pain during
coughing episodes rated as a 5 on a 0 to 10 Incorrect Options:
pain scale. S1S2 heart tones noted, All puls- Physiological: Nutrition
es palpable. Abdomen is soft and non-tender. Physiological: Mobility
Bowel sounds active in all 4 quadrants. Client Physiological: Clotting
is lying in semi-Fowler's position. Call light is Physiological: Grief
within reach.


, Swift River - Med-Surg - Scenarios
Study online at https://quizlet.com/_fpx9hw


3. Calvin Umbyuma When planning client care, which of
The nurse is planning client care and reviewing the following actions should the nurse
information in the electronic medical record take?
(EMR). During episodes of coughing, the client Correct:
expectorates sputum that is blood-tinged and Prepare to obtain a sputum specimen
greenish yellow in color. The client reports that culture
the pain increases during episodes of cough- Place the client on airborne isolation
ing. When examining the client's previous chest precautions
x-ray, the nurse identifies an area of patchy Review client's immunization record
shadowing in the right upper lobe. The client for bacillus Calmette-Guerin vaccine
reports having night sweats and waking up
through the night for the past 4 weeks being Incorrect:
drenched in sweat. The client stated that they Prepare to administer client's herbal
have traveled to Kenya twice this year to care therapies
for their ill parent. The client reports that their Preform venipuncture on client's right
parent has not received treatment for their hand to obtain blood for culture
illness at a medical facility but does practice
naturopathic medicine. The client reports us-
ing provider prescribed medications, darunavir
800 mg with ritonavir 100 mg, ...etc

4. Calvin Umbyuma Which of the following actions should
The client calls the nurse to report severe pain the nurse take?
when coughing and a worsening of shortness Correct:
of breath. When entering the client's room to Listen to the client's lung sounds
administer a PRN pain medication, the nurse Preform a medication reconciliation
notices the client has a visitor in the room who with the client's medications and ther-
has delivered the client's herbal therapy, echi- apies.
nacea and St. John's wort, from home. Monitor the client's lymphocyte
count




, Swift River - Med-Surg - Scenarios
Study online at https://quizlet.com/_fpx9hw

Incorrect:
Wear a surgical face mask when en-
tering the client's room
Place an N-95 on the client when vis-
itors enter the client's room

5. Calvin Umbyuma Correct:
Once you have 3 consecutive negative
sputum cultures you are no longer
considered contagious.
It will not be necessary to maintain
airborne precautions once you are
discharged home.
You'll have to have sputum cultures
done every 4 weeks


Incorrect:
It is important to take your medica-
tions first thing in the morning.
You'll need to take your prescribed
medications for at least 3 months
You will need to go to your provider's
office to take your daily medication
after you are discharged.

6. Calvin Umbyuma Correct
The nurse is reviewing the client's current pre- Chest X-ray
scriptions, lab work, and vital signs in the EMR. ABGs
The client is prescribed isoniazid 300 mg daily
and rifampin 600 mg daily. The client's CD4 Incorrect:
count is 300 X 1 0s/L. A consult has been Mantoux test

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