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A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy?
- A. Pupillary response
- B. Pressure in the vena cava
- C. White blood cell differential
- D. Pulmonary arterial pressure
Correct Answer: D
Rationale: If the patient has undergone surgical embolectomy, the nurse measures the patients pulmonary arterial pressure and urinary output. Pressure is not monitored in a patients vena cava. White cell levels and pupillary responses would be monitored, but not to the extent of the patients pulmonary arterial pressure.
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The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
- A. A resident who suffered a severe stroke several weeks ago
- B. A resident with mid-stage Alzheimers disease
- C. A 92-year-old resident who needs extensive help with ADLs
- D. A resident with severe and deforming rheumatoid arthritis
Correct Answer: A
Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
- A. Administer intradermal injections into the childrens inner forearms
- B. Administer intramuscular injections into each childs vastus lateralis
- C. Administer a subcutaneous injection into each childs umbilical area
- D. Administer a subcutaneous injection at a 45-degree angle into each childs deltoid
Correct Answer: A
Rationale: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply.
- A. Coping
- B. Level of consciousness
- C. Oral intake
- D. Arterial blood gases
- E. Vital signs
Correct Answer: B,D,E
Rationale: Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.
The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)?
- A. Early ambulation
- B. Increased dietary intake of protein
- C. Maintaining the patient in a supine position
- D. Administering aspirin with warfarin
Correct Answer: A
Rationale: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.
The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?
- A. Traumatic pneumothorax
- B. Empyema
- C. Pleuritic pain
- D. Myocardial infarction
Correct Answer: C
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patients vital signs profoundly.