Acute Care Exam 3 (Answered)

The nurse is caring for a patient who sustained a knee injury at work. The nurse explains that which diagnostic test best demonstrates soft tissue damage in the area of the injury? A. Knee x-ray B. Electromyography ( ...

The nurse is caring for a patient who sustained a knee injury at work. The nurse explains that which diagnostic test best demonstrates soft tissue damage in the area of the injury? A. Knee x-ray B. Electromyography (EMG) C. Computed tomography (CT) D. Magnetic resonance imaging (MRI) - ANSWER D. MRI for soft tissue damage. x-rays and CT are helpful in determining simple and complex bone fractures. EMG is for muscle problems. A 40-year-old patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for early signs of compartment syndrome? A. Numbness of the toes B. Paralysis of the left leg C. Diminished pulse in the left lower extremity D. Pain more intense than expected based on initial injury - ANSWER D. 1st sign of compartment syndrome is pain. Paralysis, numbness, and diminished pulse are late signs of compartment syndrome. The nurse is caring for a patient with crush injuries to the lower extremities. For which complication will the nurse monitor? A. Bradycardia B. Hypotension C. Acute kidney injury D. Spinal nerve injury - ANSWER C. Acute Kidney Injury Crush injuries release myoglobin from the muscle places the patient at risk for rhabdomyolysis and acute kidney injury. Patient states that he was jogging close to the edge of a hillside, and that he tripped and fell down the hill. There are no openings in the skin. A pulse cannot be obtained by touch to the right foot, which is pale and cool to palpation. The patient rates his pain as an "8" on a 0-to-10 scale. What is the priority nursing action at this time? A. Prepare for reduction. B. Administer pain medication. C. Obtain a Doppler of the right foot pulse. D. Notify the physician of the lack of a pulse in the right foot. - ANSWER C. Obtain Doppler of right foot pulse. Doppler should be done to confirm lack of pulse, then notify the physician. To control the patient's pain, which order does the nurse anticipate will be given by the provider? A. Morphine 1 to 2 mg IV B. Meperidine 50 mg IM C. Acetaminophen 650 mg by mouth D. Apply ice packs to the right ankle - ANSWER A. Morphine Acetominophene won't relieve pain 8/10. Meperidine isn't used anymore. Ice will help swelling not pain. A fiberglass cast is applied to immobilize the ankle and allow for healing. Which nursing interventions are appropriate after the cast is applied? (Select all that apply.) A. Monitor for signs of infection. B. Assess peripheral capillary refill. C. Ask the patient if he will jog in the future. D. Keep the cast uncovered for air-drying over several hours. E. Insert a finger between the skin and the cast to be sure the cast is not too tight. - ANSWER A, B, E Cast should dry within 10-15 mins. Not appropriate to ask about jogging. The patient tells the nurse that he was jogging to train for a marathon, which has been a lifelong goal. He asks, "Will I ever be able to run a marathon now?" What is the appropriate nursing response? A. "The doctor will be able to tell you that." B. "Of course, after this heals, you will be fine." C. "It is unlikely that your ankle will regain the necessary strength." D. "It sounds like you are concerned that you may not be able to achieve your goal." - ANSWER D. acknowledging the patent's goal recognizes his feelings and allows him to express his concerns. The patient's ankle heals, and his cast is removed. What teaching will the nurse provide regarding care for his ankle? A. "Scrub your lower leg and ankle to remove dead, scaly skin." B. "Wear a support stocking to prevent lower extremity swelling." C. "Keep your ankle in a low position to facilitate perfusion to the healed bone." D. "Exercise vigorously at least three times a day as directed by the physical therapist." - ANSWER B. Wear support socking to prevent swelling. Ankle should be supported, dead skin should be soaked off not scrubbed, exercises should be done slowly. To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication about the patient includes which elements? (Select all that apply.) A. Providing a recent patient history B. Communicating vital signs, allergy, and medication updates C. Verbally verifying that the operating room nurse understands the report D. Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE) E. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report - ANSWER A, B, C, D, When assessing the laboratory work of a 65-year-old patient scheduled for surgery, the nurse understand which laboratory value may result in cancellation of the surgery? A. Hemoglobin 10.5 g/dL B. Serum potassium 2.7 mEq/L C. Serum sodium level 149 mEq/L D. Fasting blood glucose 120 mg/dL - ANSWER B. Serum Potassium Slows recovery from anesthesia, increases cardiac irritability. Must be corrected before surgery Following surgery, a patient is wearing pneumatic compression devices. The patient asks, "Why do I have to wear these?" What is the most appropriate nursing response? A. "This helps to prevent blood clots." B. "It will make your legs feel more comfortable." C. "This prevents skin breakdown from immobility." D. "It will make it easier on you when you start to ambulate." - ANSWER A. Helps prevent blood clots. VTE prophylaxis may involve devices and drug therapy. Devices may be used during and after surgery along with leg exercises and ambulation to promote venous return. If patient has a shell-fish allergy what would you suspect they are also allergic to? - ANSWER Betadine Allergy. If patient is allergic to avocado, bananas, and strawberries what would you suspect they are also allergic to? - ANSWER Latex Allergy A nursing student is assessing a student upon entry to the surgical suite. Which statement by the nurse would cause the nurse to intervene? A. "Are you Mr. Green?" B. "What kind of operation are you having today?" C. "Do you have any allergies?" D. "Have you donated blood for this surgery?" - ANSWER A. Are you Mr. Green? -Join commission's national patient safety goals states correct identification of the patient is the responsibility of every member of the health care team. You should ask the patient to state their name and birthdate. Reduces errors by confused patients. The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present? A.Diabetes mellitus B.Age greater than 65 C.Impaired liver function D.Insertion of a surgical drain - ANSWER A Diabetes Mellitus -risk of infection is higher in patients with pre-existing health problems such as diabetes, immune deficiency, obesity, and kidney failure. -A surgical drain allows for the removal of secretions and fluids from within the tissues. Not having a drain could increase infection risk. Age increases risk-related skin injury from positioning and prolonged immobility during the procedure. During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention? A. Communicate the discrepancy to the surgical team immediately. B. Complete appropriate documentation concerning the error in sponge count. C. Examine the environmental distractions, refocus, and count the sponges again. D. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively. - ANSWER A Communicate the discrepancy to the surgical team immediately. - A patient has had bowel surgery. Which symptom, assessed by the nurse, is the best indicator of intestinal activity? A. Passage of flatus or stool B. Patient's report of hunger C. Abdominal cramping with distention D. Detection of bowel sounds upon auscultation - ANSWER A. Passage of flatus or stool. -The presence of active bowel sounds usually indicates return of peristalsis. Abdominal cramping along with distention shows nonmoving gas, not peristalsis. What is the priority nursing assessment when a patient is admitted to the PACU? A. Level of consciousness B. Airway and gas exchange C. Dressing and incision status D. Vital signs and body temperature - ANSWER B. Airway and gas exchange. When admired to APCu the first assessment should be patient airway and gas exchange. The other choices are second to patent airway. When positioning to promote comfort in the postoperative patient, which intervention is most appropriate? A. Raise the knee gatch of the bed. B. Place pillows under the patient's knees. C. Reposition the patient at least every 2 hours. D. Allow the patient to get out of bed as soon as possible. - ANSWER C. Reposition the patient at least every 2 hours. Raising the knee could restrict circulation. During PACU the patient most likely won't be able to get out of bed. The patient is a 63-year-old woman admitted to the acute medical care unit. She is 5ʹ4ʺ and weighs 211 lbs. Her medical history includes hypertension and GERD. On admission, she reports pain in her hands and joints that is unrelieved by OTC medications. What additional assessment data should you collect from the patient at this time? - ANSWER Based on age and reports of pain the patient is most likely experiencing osteoarthritis. This may be caused by her weight. It is important to know when the pain started and ask her to rate her pain 0-10. which OTC has she taken? how long has she experienced this pain? does she have any family history? An hour later, the patient is crying because of severe joint pain in her hands. What are your priority actions at this time? - ANSWER Assess the patient level of pain, check for pain medication orders, and PRN meds Reassess her pain level after administration of pain medication. Two hours later, laboratory values are drawn to investigate the patient's symptoms. The results are -Sodium 136 mEq/L -HCT 41.6% -Potassium 4.6 mEq/L -HGB 12.8 g/dL -Calcium 8.9 mg/dL -ESR 28 mm/hr -Are any of these results of concern? - ANSWER CBC and electrolytes are within normal limits. The ESR is high-normal which is common with osteoarthritis. A patient is newly diagnosed with osteoarthritis (OA). Which teaching is most appropriate for the nurse to include? A. OA is an immune disorder B. OA is always degenerative C. OA can be aggravated by obesity D. OA is a systemic disease - ANSWER C. OA can be aggravated by obesity. -OA is not always degenerative, not an immune disorder or systemic disorder this is associated with rheumatoid arthritis. Weight-bearing joints such as hops, and need are most often affected in obese people. The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A. Provide perineal care. B. Assess for gag reflex. C. Elevate the head of the bed. D. Perform a linen and gown change. - ANSWER C. Elevate the head of the bed. -Airway must be protected, then everything else can follow. An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would the nurse expect? (Select all that apply.) A. Constant smiling B. Intellectual impairment C. Deficits in the right visual field D. Disorientation to time, place, and person E. Inability to discriminate words and letters - ANSWER B, C, E. -Left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, deficits in the visual field. -Disorientation, smiling, and neglect of left visual field are symptoms of a right hemisphere stroke. The patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is the nurse's best response? - ANSWER Patients must meet strict eligibility criteria for thrombolytic therapy with rtPA, including giving the drug within 3 hours after the first stroke symptoms. Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is the nurse's best response? - ANSWER Before the patient is given any liquid, food, or medications he must be screened for the ability to swallow, his gag and cough reflexes must be checked. After swallow screening and it's safe he can tolerate liquids or food without aspirating fluids and food will be provided. The patient's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone? A. Apply restraints. B. Maintain the bed in a low position. C. Sit with the patient until his wife returns. D. Place the call light in the patient's right hand. - ANSWER B. restraints should not be applied until all alternate method have been attempted. Sitting with a patient for 2 hours is impractical. Call light in the right hand would not be helpful because of the right visual field deficits. The patient needs assistance with feeding, but can swallow well. To whom should the nurse delegate this responsibility? A. Hospital volunteer B. Licensed practical nurse C. Certified nursing assistant D. Student nurse doing first patient care experience - ANSWER C. Certified nursing assistant. -Feeding patients falls within the scope of practice for a CNA. A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? A.Loss of vision B.Brain stem herniation C.Intense headache D.Projectile vomiting - ANSWER B. Brain stem herniation Uneven pupils, loss of light reaction, unilateral or bilateral dilated pupils are related as herniation of the brain from ICP until proven differently. Fixed pupils are a prognostic sign and often referred to as having blown pupils. The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? A.Increased pupil size B.Nausea and vomiting C.Agitation and confusion D.Elevated blood pressure - ANSWER C. Agitation and confusion. First sign of increased ICP is declining or changing level of consciousness. Patients may be agitated or slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea, vomiting, and pupillary response occur as ICP increases. A patient has experienced a stroke in the left cerebral hemisphere. What clinical presentation does the nurse expect? (Select all that apply.)