SWIFT RIVER TEST PAPER QUESTIONS AND
SOLUTIONS EXPERT VERIFIED STUDY
CONTENT
●● Initial Nursing Assessment
Arthur Thomason is a 56-year-old client who was involved in a motor
vehicle accident (MVA). The client is four days post-operative for
splenectomy and femur repair. Arthur is experiencing new onset of
shortness of breath and is on oxygen at 2 L/min via nasal cannula with
SpO2 at 89%. The client is restless with slight confusion but easily
orientated x 3. Temperature spiked during the night to 39.1° C (102.4° F)
and last temperature check was 38° C (101°F); BP now 146/94 mm Hg,
which is slightly elevated from the client's baseline; respirations at
30/min and slightly labored; heart rate 102/min versus 84/min from last
night's shift. Skin cool to touch and appears pale. Unproductive
coughing to clear their airway. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases
demonstrate falling PaO2 (hypoxemia) and increasing CO2
(hypercapnia). The clie
Answer: Physiological: Gas Exchang,
Physiological: Acid Base
Physiological: Thermoregulation
,Psychosocial: Cognition
Physiological: Comfort
Psychosocial: Stress and Coping
Physiological: Perfusion
●● Arthur Thomason
After receiving hand-off report, the nurse enters the client's room and
observes the client talking to self. The nurse greets the client and
introduces self but notices the client appears confused. The nurse
provides reorientation to the client who is lying in supine position with
their nasal cannula not on properly. The client is dyspneic at rest and
appears restless.
Which of the following actions should the nurse take? (Select all that
apply.)
Answer: Check the client's oxygen saturation level.
Place the nasal cannula on the client properly.
Assist client to high-Fowler's position
,●● Arthur Thomason
The nursing assessment reveals lungs sounds with crackles auscultated
bilaterally; respirations 29/min on oxygen at 4 L/min. IV of D5LR
infusing to left hand at 75 mL/hr without signs of infiltration. Oral
mucosa moist, skin pale and cool to touch. Indwelling urinary catheter
draining yellow urine with 70 mL collected in two hours. Vital signs
temperature 38.5°C (101.3° F); blood pressure 148/92 mm Hg; heart rate
105/min; respirations 30/min and slightly labored; SpO2 89% on 4
L/min of oxygen. The client reports "feeling funny" with some
discomfort and appears anxious. Denies pain.
Which of the following provider's prescriptions should the nurse
anticipate? (Select all that apply.)
Answer: Obtain arterial blood gases stat.
Maintain strict intake and output.
Administer morphine 4 mg IV every
4 hours as needed for anxiety or pain.
Administer furosemide 40 mg IV push twice daily.
●● Arthur Thomason
The nurse administered morphine 4 mg IV for anxiety to the client.
Respiratory therapist placed the client on oxygen 7 L/min via simple
, face mask and SpO2 is now 94%. The client is alert and oriented x 3 and
appears calm. The client has prescriptions for acetaminophen 650 mg
PO every 4 hours PRN temperature greater than 38° C (100.4° F) and
furosemide (Lasix) 40 mg BID as diuretic. The nurse has administered
acetaminophen 650 mg PO for the client's fever and is preparing to
administer furosemide 40 mg IV to the client.
Which of the following nursing actions should the nurse take for the
administration of furosemide? (Select all that apply.)
Answer: Assess client's blood pressure before administration of
furosemide
Ask client if they have allergies to sulfonamides.
Instruct client to change positions slowly.
●● Arthur Thomason
The nurse returns to the client's room one hour later to assess the client's
status. When the nurse walks in the client's room, the client is sitting up
in bed with simple face mask hanging off their face and reports sharp
chest pain on inspiration rated as 10 on a scale of 0 to 10. The nurse
observes the client sweating, several tissues with blood-tinged sputum,
and the client appears apprehensive and states "feels like I am not going
to make it". Lung sounds with crackles, increased respirations at 34/min,
heart rate 112/min with S4 heart sounds auscultated.
SOLUTIONS EXPERT VERIFIED STUDY
CONTENT
●● Initial Nursing Assessment
Arthur Thomason is a 56-year-old client who was involved in a motor
vehicle accident (MVA). The client is four days post-operative for
splenectomy and femur repair. Arthur is experiencing new onset of
shortness of breath and is on oxygen at 2 L/min via nasal cannula with
SpO2 at 89%. The client is restless with slight confusion but easily
orientated x 3. Temperature spiked during the night to 39.1° C (102.4° F)
and last temperature check was 38° C (101°F); BP now 146/94 mm Hg,
which is slightly elevated from the client's baseline; respirations at
30/min and slightly labored; heart rate 102/min versus 84/min from last
night's shift. Skin cool to touch and appears pale. Unproductive
coughing to clear their airway. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases
demonstrate falling PaO2 (hypoxemia) and increasing CO2
(hypercapnia). The clie
Answer: Physiological: Gas Exchang,
Physiological: Acid Base
Physiological: Thermoregulation
,Psychosocial: Cognition
Physiological: Comfort
Psychosocial: Stress and Coping
Physiological: Perfusion
●● Arthur Thomason
After receiving hand-off report, the nurse enters the client's room and
observes the client talking to self. The nurse greets the client and
introduces self but notices the client appears confused. The nurse
provides reorientation to the client who is lying in supine position with
their nasal cannula not on properly. The client is dyspneic at rest and
appears restless.
Which of the following actions should the nurse take? (Select all that
apply.)
Answer: Check the client's oxygen saturation level.
Place the nasal cannula on the client properly.
Assist client to high-Fowler's position
,●● Arthur Thomason
The nursing assessment reveals lungs sounds with crackles auscultated
bilaterally; respirations 29/min on oxygen at 4 L/min. IV of D5LR
infusing to left hand at 75 mL/hr without signs of infiltration. Oral
mucosa moist, skin pale and cool to touch. Indwelling urinary catheter
draining yellow urine with 70 mL collected in two hours. Vital signs
temperature 38.5°C (101.3° F); blood pressure 148/92 mm Hg; heart rate
105/min; respirations 30/min and slightly labored; SpO2 89% on 4
L/min of oxygen. The client reports "feeling funny" with some
discomfort and appears anxious. Denies pain.
Which of the following provider's prescriptions should the nurse
anticipate? (Select all that apply.)
Answer: Obtain arterial blood gases stat.
Maintain strict intake and output.
Administer morphine 4 mg IV every
4 hours as needed for anxiety or pain.
Administer furosemide 40 mg IV push twice daily.
●● Arthur Thomason
The nurse administered morphine 4 mg IV for anxiety to the client.
Respiratory therapist placed the client on oxygen 7 L/min via simple
, face mask and SpO2 is now 94%. The client is alert and oriented x 3 and
appears calm. The client has prescriptions for acetaminophen 650 mg
PO every 4 hours PRN temperature greater than 38° C (100.4° F) and
furosemide (Lasix) 40 mg BID as diuretic. The nurse has administered
acetaminophen 650 mg PO for the client's fever and is preparing to
administer furosemide 40 mg IV to the client.
Which of the following nursing actions should the nurse take for the
administration of furosemide? (Select all that apply.)
Answer: Assess client's blood pressure before administration of
furosemide
Ask client if they have allergies to sulfonamides.
Instruct client to change positions slowly.
●● Arthur Thomason
The nurse returns to the client's room one hour later to assess the client's
status. When the nurse walks in the client's room, the client is sitting up
in bed with simple face mask hanging off their face and reports sharp
chest pain on inspiration rated as 10 on a scale of 0 to 10. The nurse
observes the client sweating, several tissues with blood-tinged sputum,
and the client appears apprehensive and states "feels like I am not going
to make it". Lung sounds with crackles, increased respirations at 34/min,
heart rate 112/min with S4 heart sounds auscultated.
