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Med Surg Exam 3 Study Guide

After a patient has undergone a rhinoplasty, which nursing intervention will be included in theplan of care?
a. Educate the patient about how to safely remove and reapply nasal packing.
b. Reassure the patient that the nose will look normal when the swelling subsides.
c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain.
d. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.
Rationale : Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by thesurgeon on the day after surgery. Although return to a preinjury appearance is the goal of thesurgery, it is not always possible to achieve this result.
After discussing management of upper respiratory infections (URI) with a patient who has acuteviral rhinitis, the nurse determines that additional teaching is needed when the patient says
a. I can take acetaminophen (Tylenol) to treat discomfort.‖
b. I will drink lots of juices and other fluids to stay hydrated.‖
c. I can use my nasal decongestant spray until the congestion is all gone.‖
d. I will watch for changes in nasal secretions or the sputum that I cough up.‖
Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask?
a. How much alcohol do you drink in an average week?‖
b. Do you have a family history of head or neck cancer?‖
c. Have you had frequent streptococcal throat infections?‖
d. Do you use antihistamines for upper airway congestion?‖
Rationale: Prolonged alcohol use and smoking are associated with the development of laryngeal cancer,
which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever.
Which of these patients in the respiratory disease clinic should the nurse assess first?
a. A 23-year-old, complaining of a sore throat, who has a hot potato voice
b. A 34-year-old who has a scratchy throat‖ and a positive rapid strep antigen test
c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
Rationale: The patient's clinical manifestation of a hot potato voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems
The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
Rationale: The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake
Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN or LVN who is caring for a patient with a permanent tracheostomy?
a. Assessing the patient's risk for aspiration
b. Suctioning the tracheostomy when needed
c. Educating the patient about self-care of the tracheostomy
d. Determining the need for replacement of the tracheostomy tube
Rationale: Suctioning of a stable patient can be delegated to LPN or LVNs. Assessments and patient teaching should be done by the RN
The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient's temperature is 100.1° F (37.8° C).
d. The patient complains of level 7 (0 to 10 scale) pain.
Rationale: Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O2 saturation.
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurseuse to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Educate the patient about the need for fluid restrictions
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse?
a. I will call the doctor if I still feel tired after a week.‖
b. I will need to use home oxygen therapy for 3 months.‖
c. I will continue to do the deep breathing and coughing exercises at home.
d. I will schedule two appointments for the pneumonia and influenza vaccines.‖
Rationale: Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time
Which nursing action will be most effective in preventing aspiration pneumonia in patients whoare at risk?
a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV)antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient's white blood cell (WBC) count is 9000 per µl.
d. Increased tactile fremitus is palpable over the right chest.
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other datas uggest that a change in treatment is needed.
Which information about a patient who has a recent history of tuberculosis (TB) indicates thatthe nurse can discontinue airborne isolation precautions?
a. Chest x-ray shows no upper lobe infiltrates
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
Rationale: Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. washes dishes and personal items after use.
c. covers the mouth and nose when coughing.
d. reports daily to the public health department.
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Educating the patient about the long-term impact of TB on health
b. Giving the patient written instructions about how to take the medications
c. Teaching the patient about the high risk for infecting others unless treatment is followed
d. Arranging for a daily noontime meal at a community center and giving the medication then
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
a. computed tomography (CT) screening for lung cancer.
b. options for smoking cessation.
c. reasons for annual sputum cytology testing.
d. erlotinib (Tarceva) therapy to prevent tumor risk.
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors
A patient with newly diagnosed lung cancer tells the nurse, ―I think I am going to die pretty soon.‖ Which response by the nurse is best?
a. Would you like to talk to the hospital chaplain about your feelings?
b. Can you tell me what it is that makes you think you will die so soon?‖
c. Are you afraid that the treatment for your cancer will not be effective?‖
d. Do you think that taking an antidepressant medication would be helpful?‖
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning ―Can you tell me what it is‖ is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, ―Are you afraid‖ implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate
When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for
a. emergency pericardiocentesis.
b. stabilization of the chest wall with tape.
c. administration of an inhaled bronchodilator.
d. insertion of a chest tube with a chest drainage system.
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems
A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). Thenurse will evaluate that the treatment is effective if
a. the BP is less than 140|90 mm Hg.
b. the patient reports decreased exertional dyspnea.
c. the heart rate is between 60 and 100 beats |minute.
d. the patient's chest xray indicates clear lung fields.
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective
Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?
a. BP is 150|90 mm Hg.
b. Oxygen saturation is 89%.
c. Pain level is 5|10 with a deep breath.
d. Respiratory rate is 24 when lying flat.
Rationale: Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89%indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority
A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6°F with a frequent cough and is complaining of severe pleuritic chest pain. Which of the seprescribed medications should the nurse give first?
a. guaifenesin (Robitussin)
b. acetaminophen (Tylenol)
c. azithromycin (Zithromax)
d. codeine phosphate (Codeine)
Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy
A patient with chronic bronchitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that
a. one drug decreases inflammation, and the other is a bronchodilator.
b. Advair is a combination of long-acting and slow-acting bronchodilators.
c. the combination of two drugs works more quickly in an acute asthma attack.
d. the two drugs work together to block the effects of histamine on the bronchioles.
Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not use dduring an acute attack because the medications do not work rapidly
When preparing a patient with possible asthma for pulmonary function testing, the nurse willteach the patient to
a. avoid eating or drinking for several hours before the testing.
b. use rescue medications immediately before the tests are done.
c. take oral corticosteroids at least 2 hours before the examination.
d. withhold bronchodilators for 6 to 12 hours before the examination.
Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective?
a. No wheezes are audible.
b. Oxygen saturation is >90%.
c. Accessory muscle use has decreased.
d. Respiratory rate is 16 breaths|minute.
Rationale: The goal for treatment of an asthma attack is to keep the oxygen saturation >90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack
A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take?
a. Teach the patient about the use of oral corticosteroids.
b. Administer a bronchodilator and recheck the peak flow.
c. Instruct the patient to continue to use current medications.
d. Evaluate whether the peak flow meter is being used correctly.
Rationale: The patient's peak flow readings indicate good asthma control, and no changes are needed. The other actions would be used for patients in the yellow or red zones for peak flow
A 32-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of emphysema. The nurse will anticipate teaching the patient about
a. Alpha-1-antitrypsin testing.
b. use of the nicotine patch.
c. continuous pulse oximetry.
d. effects of leukotriene modifiers.
Rationale: When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in alpha-1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema
Which information about a newly admitted patient with chronic obstructive pulmonary disease(COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline?
a. The patient has had a recent 10-pound weight gain.
b. The patient has a cough productive of green mucus.
c. The patient denies any shortness of breath at present.
d. The patient takes cimetidine (Tagamet) 150 mg daily.
Rationale: Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not impact on whether the theophylline should be administered or not
When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis?
a. The patient tells the nurse about a family history of bronchitis.
b. The patient's history indicates a 40 pack-year cigarette history.
c. The patient denies having any respiratory problems until the last 6 months.
d. The patient complains about a productive cough every winter for 3 months.
Rationale: A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis
Which action will the nurse in the hypertension clinic take in order to obtain an accurate baselineblood pressure (BP) for a new patient?
a. Obtain a BP reading in each arm and average the results.
b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
c. Have the patient sit in a chair with the feet flat on the floor.
d. Assist the patient to the supine position for BP measurements.
Rationale: The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.
The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient?
a. Low dietary fiber intake
b. No regular aerobic exercise
c. Weight 5 pounds above ideal weight
d. Drinks wine with dinner once a week
Rationale: The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk
A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient?
a. Check BP daily before taking the medication.
b. Increase fluid intake if dryness of the mouth is a problem.
c. Include high-potassium foods such as bananas in the diet.
d. Change position slowly to help prevent dizziness and falls.
Rationale: The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate
A client is ordered to receive propranolol (Inderal). The nurse notes that the client has a history of asthma. The nurse calls the ordering physician with the knowledge that propranolol may cause:
a. no change in airway
b. bronchial constriction
c. bronchial dilation.
d. bronchial enlargement.
Rationale: As a beta-blocker, propranolol (Inderal) may cause airway constriction, exacerbating the asthmatic changes.
The nurse in the emergency department received change-of-shift report on four patients withhypertension. Which patient should the nurse assess first?
a. 52-year-old with a BP of 212|90 who has intermittent claudication
b. 43-year-old with a BP of 190|102 who is complaining of chest pain
c. 50-year-old with a BP of 210|110 who has a creatinine of 1.5 mg|dL
d. 48-year-old with a BP of 200|98 whose urine shows microalbuminuria
Rationale: The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.
The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
a. weight loss of 2 pounds overnight.
b. improvement in hourly urinary output.
c. reduction in systolic BP.
d. decreased dyspnea with the head of the bed at 30 degrees.
Rationale: Because the patient's major clinical manifestation of ADHF acute decompensated heart failure is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response
The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) below this percentage receive an ACE inhibitor to decrease the progression of heart failure.
a. 10%
b. 15%
c. 30%
d. 40%
Rationale: The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure.

What is normal ejection fraction?
Ejection Fraction Measurement What it Means
55-70% Normal
40-55% Below Normal
Less than 40% May confirm diagnosis of heart failure
<35% Patient may be at risk of life-threatening irregular heartbeats
The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient
a. says that the nitroglycerin patch will be used for any chest pain that develops.
b. calls when the weight increases from 124 to 130 pounds in a week.
c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime
d. makes an appointment to see the doctor at least once yearly.
Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
a. eggs and other high-cholesterol foods.
b. canned and frozen fruits.
c. fresh or frozen vegetables.
d. milk, yogurt, and other milk products.
Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000 mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.
Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
a. digitalis preparations, such as digoxin (Lanoxin).
b. calcium-channel blockers, such as diltiazem (Cardizem).
c. -adrenergic agonists, such as dobutamine (Dobutrex).
d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).
Rationale: ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and B-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The B-adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170|100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to
a. auscultate the lung sounds.
b. assess the orientation.
c. check the capillary refill.
d. palpate the abdomen.
Rationale: This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac|respiratory arrest.
A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to
a. administer IV morphine sulfate 2 mg.
b. give IV diazepam (Valium) 2.5 mg.
c. increase dopamine (Intropin) infusion by 2 mcg|kg|min.
d. increase nitroglycerin (Tridil) infusion by 5 mcg|min.
Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.
A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's
a. weight increases from 120 pounds to 122 pounds over 3 days.
b. liver is palpable 2 cm below the ribs on the right side.
c. serum potassium level is 3.0 mEq|L after 1 week of therapy.
d. has 1 to 2+ edema in the feet and ankles in the morning
Rationale: Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?
a. Statins
b. Vitamins
c. Thrombolytics
d. Anticoagulants
Rationale: Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD
The nurse performing an assessment with a patient who has chronic peripheral artery disease(PAD) of the legs and an ulcer on the left great toe would expect to find
a. A positive Homans' sign.
b. swollen, dry, scaly ankles.
c. prolonged capillary refill in all the toes.
d. a large amount of drainage from the ulcer.
Rationale: Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease
In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says:
a. I will have to buy some loose clothing that does not bind across my legs or waist.‖
b. I will usea heating pad on my feet at night to increase the circulation and warmth in my feet.‖
c. I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.‖
d. I will change my position every hour and avoid long periods of sitting with my legs down.‖
Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?
a. Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.‖
b. Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.‖
c. The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.‖
d. Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.‖
Rationale: Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE
The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says:
a. I should reduce the amount of green, leafy vegetables that I eat.‖
b. I should wear a Medic Alert bracelet stating that I take Coumadin.‖
c. I will need to have blood tests routinely to monitor the effects of the Coumadin.‖
d. I will check with my health care provider before I begin or stop any medication.‖
Rationale: Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate
What labs are monitored for pt inr know normal ranage
normal range of PT|INR = 12-13|0.8-1.2. (on coumadin 2-3)
Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?
a. Adequate carbohydrate intake
b. Prophylactic antibiotic therapy
c. Application of compression to the leg
d. Methods of keeping the wound area dry
Rationale: Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing
A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?
a. I can't get my shoes on at the end of the day.‖
b. I can never seem to get my feet warm enough.‖
c. I wake up during the night because my legs hurt.‖
d. I have burning leg pains after I walk three blocks.‖
Rationale: Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD