Nokea
The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?
- A. The patient is experiencing painless hemoptysis
- B. The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing
- C. The patients oxygen saturation level is below 88%, but he denies shortness of breath
- D. The patients pain intensifies when he coughs or takes a deep breath
Correct Answer: D
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patients ABGs would most likely be abnormal and shortness of breath would be expected.
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The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?
- A. Assess the patients level of consciousness (LOC)
- B. Assess the patients extremities for signs of cyanosis
- C. Assess the patients oxygen saturation level
- D. Review the patients hemoglobin, hematocrit, and red blood cell levels
Correct Answer: C
Rationale: The effectiveness of the patients oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patients LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.
The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?
- A. Coumadin will continue to break up the clot over a period of weeks
- B. Coumadin must be taken concurrent with ASA to achieve anticoagulation
- C. Anticoagulant therapy usually lasts between 3 and 6 months
- D. He should take a vitamin supplement containing vitamin K
Correct Answer: C
Rationale: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.
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.
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?
- A. A chest tube
- B. A tracheostomy
- C. An endotracheal tube
- D. A feeding tube
Correct Answer: B
Rationale: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication?
- A. Acute respiratory distress syndrome (ARDS)
- B. Atelectasis
- C. Aspiration
- D. Pulmonary embolism
Correct Answer: B
Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.