Adult Health 4 - Exam 1 PDF

Adult Health 4 - Exam 1 Kahoot Calcium Channel Blockers: ACE Inhibitors “-PRIL” Meds: Chest Tubes: Chapter 17: Fluid and Electrolyte Balances Questions: Chapter 18 - Preoperative Care Questions: Chapter 19 - Intraoperative Care Questions: Chapter 20 - Postoperative Care Questio...

Adult Health 4 - Exam 1 Kahoot Calcium Channel Blockers: ACE Inhibitors “-PRIL” Meds: Chest Tubes: Chapter 17: Fluid and Electrolyte Balances Questions: Chapter 18 - Preoperative Care Questions: Chapter 19 - Intraoperative Care Questions: Chapter 20 - Postoperative Care Questions: Chapter 21 - Emergency and Disaster Nursing Questions: Chapter 26 - Burns Questions: Chapter 28 - Supporting Ventilation Questions: Chapter 44 - Nutrition Problems Questions: Chapter 67 - Musculoskeletal Trauma and Orthopedic Surgery Questions:  Kahoot Carbon monoxide (CO) poisoning spot symptoms nonspecific ranging from dizziness & HA to unconsciousness & death CO has 200–250times greater affinity for hemoglobin than 02 does initiation of 100% 02 breathing asap is the most important treatment *** Myocardial injury occurs freq in pts hospitalized s/mod to severe CO poison PARALYZE sedated The drugs succinylcholine and mivacurium are both metabolized by the pseudocholinesterase enzyme - If someone has a pseudocholinesterase deficiency - they are not gonna wake up quickly Pts with defective forms of pseudocholinesterase will have a reduced ability to metabolize succinylcholine & mivacurium If vitals signs change suddenly in a patient what should the RN do.... Assess - take blood pressure again (manually) Check the pt’s line make sure they aren’t kinked/connected to the right places *** Check if O2 is connected & flush their IV line End-tidal Co2 monitors are currently recommended for rapid verification of ET placement. - Xray is gold standard - Color changes purple to yellow - If NOT done - risk for hypoxia colormetric Causes of ineffective cough include: muscle weakness impaired chest mobility GAGE Weakness of the respiratory or abdominal muscles increased mucus viscosity, and ciliary dysfunction If they cannot protect their airway they can aspirate - INTUBATION *** Smoke and soot inhalation are common injuries to the pulmonary tree causing respiratory CEE difficulty Prealbumin is the most sensitive indicator of protein synthesis and catabolism - Important for burn pts NORA 6 30 Early enteral nutrition benefits are associated with decreasing pneumonia, mortality, ICU length of stay - Goal is to feed the gut in 24 hrs  Nutritional goals not being met = pt experiences weight loss, elevated glucose levels & either overhydration/dehydration LDL Lipids… PROPOFOL CHECKHDL NO triglyceride levels must be monitored until stable when admin lipids - monitor before administration are very good media for bacterial growth tubing should be changed every 24 hours (same w/ TPN) Do not give with propofol due to too much lipids - high tri levels Parenteral nutrition medications are not administered through the IV lines containing TPN/lipids (or arterial lines) risks include elevated blood sugar, infection & volume overload - assess for s/s of overload (lung sounds, SOB, edema) glucose is monitored during treatment (Q6) Ventricular tachycardia is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles Go assess pt, check for pulse, call rapid, pt may require chemical conversion (if alive) or electricity synchronized cardioversion *** HCP is GOING to ask about potassium and magnesium when called When pt is unresponsive RN should open pt airway by using the head-tilt, chin-lift because it prevents further injury C Captopril *** may cause hyperkalemia, angioedema, cough, renal insufficiency, flushing SPINNIEIYI.tn should be taken 1 hour before meals. med used in mgmt of HTN, left ventricular dysfctn after MI, DM nephropathy 2 ACE inhib don't have to be activated in body lisinopril and captopril The nurse should use the IV route for pain meds in a pt who sustained a large burn rapid absorption & pain relief - never IM or SubQ A burn pt should increase protein consumption, which promotes wound healing & prevents tissue breakdown A nurse should limit visitors & ensure they are not ill to prevent infection with burn pt with severe skin injuries XP A nurse should not allow fresh flowers to be delivered to a patient with a large severe burn to prevent infection  EASON MAI Wear protective equipment when entering burn pts room (gown, mask, gloves) What is the minimum amount of UOP per hour for a burn patient 30ml Arterial lines the RN should… (not on exam 1) should check a line and the 5 p's every hour I make sure all connections are secure and that the transducer is zeroed out should ensure the pressure bag is inflated adequately to prevent problems monitor the waveform for dampening, and maintain a press. flush solution Hemothorax is a serious condition in which blood collects in your pleural space Clinical sign of hemothorax: resp distress, tachypnea, decreased/ absent breath sounds, dullness to percussion... Pneumothorax -air gets inside your chest cavity and creates pressure against the lung, causing it to collapse partially/fully. In pts with reversible airway disease, beta-blockers may increase airway reactivity and bronchospasm In the setting of a possible cervical spine injury, jaw-thrust maneuver,-- neck is held in a neutral position, is preferred Excess fluid of a pulmonary contusion interferes with gas exchange, potentially leading to hypoxia. DVT becomes more likely if you have one or more of these risk factors Family history of blood clots. excessive blood clotting Having a long-term (indwelling) catheter, a tube in a blood vessel. sedentary due to bed rest or sitting too long without moving If pt has trauma Transcutaneous pacing DIC temporary method of pacing pts with severe symptomatic bradyarrhythmias allows fast, efficient, and noninvasive ventricular stimulation temporary cardiac pacing using pads or paddles applied externally to the chest Assess hemodynamic response to pacing by assessing central pulses Ordes for both transcutaneous pacing & atropine - USE TRANSCUTANEOUS FIRST b/c it’s effective 100% of the time **** Anesthesia if time allows Is Atropine only works on SANODE SO 30HB NEEDSTCP  Notify the provider if any of the following occurs in your pt with a chest tube: Drainage stops within the first 24 hours after the chest tube is inserted decreased/absent lung sounds can indicate worsening pneumothorax/hemothorax Drainage averages more than 200 mL/hour for 4 hours. Drainage appears cloudy because this can be a sign of infection. Lorazepam is a benzodiazepine used for the management of anxiety disorders, insomnia, panic attacks& alcohol withdrawal Hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately Flail chest can cause instability causing thorax to move in during inspiration and out during expiration - Threshold for intubation; fail chest has a 33% mortality rate Anaesthesia should be provided for cardioversion if time allows because it is extremely stimulating & painful procedure (propofol) ORVERSED Be Most common signs and symptoms of a transfusion reaction include fever, chills, urticaria, and itching. - If this occurs stop the infusion - MUST stay with patient for at least the first 15 mins (she said 20 mins but she emphasized the book says 15) *** ÑY Premature ventricular contraction (PVC) is caused by an ectopic cardiac pacemaker located in the ventricle man of Most mass casualty incident triaging systems use tags or colored designations for categorizing injured persons ASAP IHR 2HR - Red - life-threatening; yellow - possibly life-threatening; green - non-life threatening; black - dead When therapeutic hypothermia is used, external cooling devices or cold NS infusions are used to lower body temp rapidly - TTM is neuro-protective “puts brain on bedrest” = better chance of recovery w/ no brain damage When possible, life-threatening injury is found during primary survey RN should start interventions before proceeding w/ survey Furosemide is a loop diuretic used for high potassium (she kept emphaizing tx of hyperkalemia) ***  GRAPEFRUIT NO Diltiazem is a calcium channel blocker that can cause bradycardia - Check apical pulse for a full minute before admin A temporary pacemaker is indicated for third-degree heart block and if the patient is symptomatic Atropinewontwork Left heart failure DM, smoking, obesity, male gender&sedentary lifestyle are considered risk factors common causes are coronary artery disease and hypertension. can lead to severe volume overload leading to resp distress, shock pts present w/SOB, orthopnea, paroxysmal nocturnal dyspnea&/volume overload The jugular vein conduit of blood in continuity with the right atrium one of the central veins of the body quick way to assess volume status and cardiac function. pt becomes fluid overloaded, right heart pressure will increase causing JVD RN should identify that 02 should be readily available in case pt develops resp distress following chest tube placement If the chest tubing becomes disconnected the end of tubing should be placed in sterile water to restore the water seal - have sterile water at bedside - Place sterile gauze over dressing occlude 3 sides allows air to be released from open side Hemostat clamps should be available in the room of a patient with a chest tube. - There in case of emergency “don’t ever use them” If the chest tubing becomes disconnected the nurse should immediately place a sterile gauze dressing over the site To Gentle bubbling in the suction control chamber is normal and indicates that air that is trapped is being removed. A chest tube drainage system should never be milked or striped as it may cause a life threatening obstruction If the CT drainage collection system is damaged in any way, insert patient's chest tube into a bottle of sterile water. If the chest tube dislodges from pt, the insertion site should be covered with sterile occlusive dressing taped on 3 sides Biffe I ps Biforada  go Taping on 3 sides allows air to escape on the fourth side to reduce the risk of a tension pneumothorax IV medication is given to sedate pt, prior to cardioversion. Because shock would be painful for a patient who is awake Crush injuries and Burns can cause... metabolic abnormal -K released from ischemic muscle into the systemic circulation Renal Failure-Rhabdomyolysis releases myoglobin, K, P, & Cr - risk for AKI cardiac arrhythmias Hypotension Drowning is a cause of significant global mortality. Mechanism of injury involves inhalation of H20, lung injury, and hypoxia Initial actions of the nurse are focused on ABCs—airway, breathing, & circulation—and administration of O2 & safety Localized catheter infections include exit site infections. May present w/signs of inflammation purulence or cellulitis. - Always check for lines if pt becomes septic Pt has dyspnea & chest pain in association with a new rhythm, the nurse's initial actions should be to address the patient’s... Airway Breathing Circulation Arterial blood gases (not on exam 1) 1st step is to look at the pH &assess for the presence of acidemia ph Modified Allen test is a must before an ABG is drawn standard for assessing a patient's oxygenation, ventilation, and acid-base status recommended to evaluate a patient’s response to therapeutic interventions Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Airway, Breathing, Circulation, Disability, Safety approach is a systematic approach to the immediate assessment Basic tenets of critically ill patient management remain focused on initial attention to airway, breathing, and circulations. Therapeutic Hypothermia (TH)  temperature should be maintained between 32ºC and 36ºC Hypothermia should be induced ASAP to achieve maximum neuroprotection and edema Hypothermia treatment helps provide neuroprotection in anoxic brain injury improves neurological recovery and reduces mortality after global ischemia The Glasgow Coma Scale (GCS) A GCS score of 8 or less defines a severe head injury. = INTUBATION maximum score of 15 and a minimum score of 3, used to describe the general level of consciousness in pts with TBI & head injury 3 categories, eye-opening (E), motor response (M), and verbal response (V) An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Primary adverse effects of prednisone: hyperglycemia, insomnia, increased appetite, HTN, osteoporosis, edema What loop diuretic, can be prescribed to relieve manifestations of circulatory overload? FUROSEMIDE Verapamil has a strong affinity for myocardium & vascular smooth muscle it Suppresses cardiac contractility and SA nodal automaticity Metoprolol Metoprolol administration can be either oral or intravenous. 1 adverse effects of metoprolol include heart failure exacerbation, fatigue decreases cardiac output by negative inotropic and chronotropic effects cardioselective beta-1-adrenergic receptor inhibitor Calcium channel blockers *** slows cardiac conduction &contractility, allows for tx of hypertension. adverse effects may cause constipation, worsening CO,&bradycardia drug class is one of the leading causes of drug-related fatalities Hypotension&bradycardia seen in calcium channel antagonist poisoning ? Angiotensin-converting enzyme decreasing afterload, preload &systolic wall stress, results in increased CO used to treat and manage hypertension reduces overall mortality, especially w/ heart failure w/reduced ejection frac may cause hyperkalemia & angioedema are the most significant adverse effect Synchronized cardioversion used to treat atrial fibrillation (AF), atrial flutter, and stable VT performed on pts that still have a pulse but are hemodynamically unstable  preventing LOW ENERGY SHOCK uses a sensor to deliver electricity synchronized w/peak of QRS Treats both hemodynamically unstable ventricular and supraventricular rhythm Medicate if time allows Urine output reduction is indicative of MODs, dehydration, or renal failure. - MAP needs to be greater than 65 to perfuse kidneys (“according to Lewis”) Patients who suddenly become immobile are predisposed to deep vein thrombosis. Flail segment chest wall will negatively affect respiration 3 ways: ineffective ventilation, pulmonary contusion, and hypoventilation Tetanus can lead to the inability to swallow/breath. Adults should receive a booster dose of either Tdap or Td every 10 yrs - No/unknown vax status - give anyway Diphtheria and pertussis spread from person to person. Tetanus enters the body through cuts or wounds. Mass casualty incidents triage systems implemented to offer the greatest good to the greatest amt of people goal is - move pts away from incidents & toward resourcesforcomprehensivecare use tags or colored designations for categorizing injured persons Complaints of chest burning may indicate chest tube is kinked, or compressed, which can impair drainage and ventilation Beneficence refers to the ethical principle of doing good or acting in the best interest of the patient. Asking questions requiring informative answers helps identify effectiveness of coping strategies currently used by pt What are the 5 levels of the social-ecological model? 1. Intrapersonal 2. Interpersonal 3. organizational 4. environmental 5. policy Abraham Maslow was one of the founders of humanistic psychology and the famous hierarchy of needs Direct injury to blood vessels can cause damage leading to thrombosis and promote venous stasis - DVT is a HUGE problem for trauma pts Abdominal wound dehiscence with evisceration Place saline-soaked gauze over the wound & protruding organs, take VS, call HCP Placing pt upright seated position &using bedside ultrasound can aid in ID fluid pockets in pts with lower fluid volume Fat embolism syndrome (FES) is a rare syndrome that, when severe, is associated with respiratory failure Acute salicylate overdose onset of symptoms will occur within 3 to 8 hr. Severity of symptoms dependent on amountt ingested mild ingestion-N/V, generalized abdominal pain, tinnitus HA, & tachypnea moderate-more severe neuro symptoms. Tachypnea pronounced, increased HR severe-dehydrated, obtunded, seizures. Hypoventilation replaces hyperventilation *** Anything related to mental health is coming straight from ATI *** chapter 67 (musculoskeletal that ch is really not gonna be on the test someone specifically asked) *** She re-emphaized calcium channel blockers at least 10x - so really know your stuff with those Calcium Channel Blockers: Diltiazem is prescribed for a patient newly diagnosed with Prinzmetal‘s (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? a. Reduces heart palpitations. b. Prevents coronary artery plaque. c. Decreases coronary artery spasms. d. Increases contractile force of the heart. ANS: C Prinzmetal‘s angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand. Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions, such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions. Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching? a. Calcium channel blocker b. Selective SA node inhibitor c. Digoxin and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitor ANS: D 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 drugs such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. Ivabradine would likely be used for a patient with HF who has symptoms despite optimal doses of other medications. A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which action would the nurse take? a. Reposition the patient on the left side. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads. ANS: D The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. Repositioning on the left side may decrease cardiac output and blood pressure further. Which additional information would the nurse consider when reviewing the laboratory results for a patient‘s total calcium level? a. The blood glucose b. The serum albumin c. The phosphate level d. The magnesium level ANS: B Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of total calcium levels, while ionized calcium levels are unchanged by inconsistent serum albumin levels. The other laboratory values will not affect total calcium interpretation. ACE Inhibitors “-PRIL” Meds: Which information would the nurse teach the patient who has been prescribed captopril? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check the blood pressure in both arms before taking the drug. ANS: C The angiotensin-converting enzyme (ACE) inhibitors often 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 drug. The patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate. The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. “The medication may not work well if I take aspirin.” b. “I can expect some swelling around my lips and face.” c. “The doctor may order a blood potassium level occasionally.” d. “I will call the doctor if I notice that I have a frequent cough.” ANS: B Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor would be discontinued. The patient would be taught that if any swelling of the face or oral mucosa occurs, the health care provider would be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy. The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a prescription for enalapril (Vasotec). Which statement by the new nurse to the patient requires the charge nurse‘s intervention? a. “Make an appointment with the dietitian for teaching.” b. “Increase your dietary intake of high-potassium foods.” c. “Check your blood pressure at home at least once a day.” d. “Move slowly when moving from lying to sitting to standing.” ANS: B ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril. The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient‘s blood pressure (BP) continues to be high. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient uses ibuprofen to treat osteoarthritis. c. Patient checks BP daily just after getting up. d. Patient drinks wine three to four times a week. ANS: B Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient‘s alcohol intake is not excessive. A patient with diabetes mellitus and chronic stable angina has a new order for captopril. Which information would the nurse teach this patient about the primary purpose of captopril? a. Decreases the heart rate. b. Controls blood glucose levels. c. Prevents changes in heart muscle. d. Reduces the frequency of chest pain. ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate. A hospitalized patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. “I plan to take the medication with food.” b. “I should eat more potassium-rich foods.” c. “I will call for help when I need to get up to use the bathroom.” d. “I can expect to feel more short of breath for the next few days.” ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of -adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving? a. Captopril (Capoten) 25 mg b. Furosemide (Lasix) 60 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg ANS: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients in pulmonary edema with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. -Blockers can reduce myocardial contractility, so care must be taken in patients with volume overload. The other drugs are appropriate for the patient with ADHF. A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also 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. What laboratory value would the nurse check before administering captopril to a patient with stage 2 chronic kidney disease? a. Glucose b. Potassium c. Creatinine d. Phosphate ANS: B Angiotensin-converting enzyme (ACE) inhibitors are often used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect administration of captopril. Chest Tubes: A postoperative patient has a right-sided pleural chest tube connected to a chest drainage device. There is continuous bubbling in thesuction-control chamber of thewet-suction collection device. Which action would thenurse take? a. Adjust thedial on thewall regulator. b. Continue to monitor thecollection device. c. Document thepresence of a large air leak. d. Notify thesurgeon of a possible pneumothorax. ANS: B Continuous bubbling is expected in thesuction-control chamber of a wet-suction device and indicates that thesuction-control chamber is connected to suction. An air leak would be detected in thewater-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing thevacuum source will not adjust thesuction pressure. theamount of suction applied is regulated by theamount of water in this chamber and not by theamount of suction applied to thesystem. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could thenurse delegate to theassistive personnel (AP)? a. Document theamount of drainage every 8 hours. b. Obtain samples of drainage for culture from thesystem. c. Assess patient pain level associated with thechest tube. d. Check thewater-seal chamber for thecorrect fluid level. ANS: A AP education includes documentation of intake and output. theother actions are within thescope of practice and education of licensed nursing personnel. An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take? a. Turn and reposition the patient. b. Administer prescribed morphine. c. Clamp the chest tube in two places. d. Assist the patient with incentive spirometry. ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough or tolerate repositioning until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax. The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain would be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema would be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed. The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction ANS: D 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 to suction. 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. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (AP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level. ANS: A AP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel. Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time. ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound. Chapter 17: Fluid and Electrolyte Balances LEARNING OUTCOMES 1. Describe the composition of the major body fluid compartments. 2. Define processes involved in regulating water and electrolyte movement between the body fluid compartments. 3. Describe the etiology, manifestations, and interprofessional management of: a. Extracellular fluid volume imbalances: fluid volume deficit and fluid volume excess b. Sodium imbalances: hypernatremia and hyponatremia c. Potassium imbalances: hyperkalemia and hypokalemia d. Magnesium imbalances: hypermagnesemia and hypomagnesemia e. Calcium imbalances: hypercalcemia and hypocalcemia f. Phosphate imbalances: hyperphosphatemia and hypophosphatemia 4. Identify the processes involved in maintaining acid-base balance. 5. Discuss the etiology, manifestations, and nursing and interprofessional management of acid-base imbalances: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. 6. Describe the composition of and indications for common IV fluid solutions. 7. Discuss the types and nursing management of commonly used central venous access devices. KEY TERMS: acidosis alkalosis buffers central venous access devices (CVADs) electrolytes fluid spacing hydrostatic pressure hypercalcemia hyperkalemia hypernatremia hypertonic hypocalcemia hypokalemia hyponatremia hypotonic isotonic Osmolality  Ca Mg sedate P my To Reflexes M Hard are go.EE Kusmfal's Resp DKA Questions: 1. During the postoperative care of a 76-year-old patient, the nurse monitors the patient’s intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids.  b. older adults are more likely than younger adults to lose extracellular fluid during surgeries. c. water accounts for a greater percentage of body weight in the older adult than in younger adults. d. small losses of fluid are significant because body flu- ids account for 45% to 50% of body weight in older adults. 2. During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is (recognize) a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion. 3a. An older adult is admitted to the medical unit with GI bleeding. Assessment findings that occur with fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. orthostatic f. Hypotension. g. increased central venous pressure. 3b. The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter. 3c. The nurse should be alert for which manifestations in a patient receiving a loop diuretic? hypokalemia a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms 3d. Which patient is at greatest risk for developing hypermag- nesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-adren-ergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection 3e. It is important for the nurse to assess for which manifesta- tion(s) in a patient who has just undergone a total thyroid- ectomy? (select all that apply) a. Confusion b. Weight gain c. Depressed reflexes He fCatt d. Circumoral numbness PCa e. Positive Chvostek sign 3f. The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products. 4. The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load. 5. A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse deter- mines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis. 6. The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer’s solution. d. 5% dextrose in 0.45% saline. 7. The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. try to force 10 mL of normal saline into the device. c. place the patient on the left side with the head down. d. have the patient change positions, raise arm, and cough. ANSWERS: 1. d; 2. a; 3a. a, b, e; 3b. a; 3c. c; 3d. c; 3e. a, d, e; 3f. b; 4. a; 5. d; 6. c; 7. d. Chapter 18 - Preoperative Care LEARNING OUTCOMES 1. Distinguish the common purposes and settings of surgery. 2. Describe the purpose and components of a preoperative nursing assessment. 3. Interpret the significance of data related to the preoperative patient’s health status and operative risk. 4. Analyze the components and purpose of the patient’s informed consent for surgery. 5. Examine the nursing role in the preparation of the surgical patient. 6. Prioritize the nursing responsibilities related to day-of- surgery preparation for the surgical patient. 7. Discern the purposes and types of common preoperative drugs. 8. Plan care to include special considerations of preoperative preparation for the older adult surgical patient. KEY TERMS ambulatory surgery elective surgery emergency surgery informed consent perioperative same-day admission surgery Questions: 1. A patient with obesity (BMI 42.1 kg/m2) is scheduled for a laparoscopic cholecystectomy in an outpatient surgery setting. Which information would the nurse include in the plan of care? a. The patient will be in the hospital for several days. b. Surgery will involve removing a part of the liver. c. The setting is not appropriate for the planned procedure. d. Special equipment may be needed for the patient’s care. 2. The patient reports that she has noticed a skin reaction when wearing disposable gloves. Which action would the nurse take? a. Notify the surgeon so that the surgery can be canceled. b. Ask further questions to assess for a possible latex allergy. c. Notify the OR staff at once so they can use latex-free sup-plies. d. No action is needed because the patient’s reaction has no bearing on surgery. 3. A 59-year-old man scheduled for a herniorrhaphy in 2 days reports that he takes an anticoagulant agent daily. Which action would the nurse take? a. Inform the surgeon since the procedure may have to be rescheduled. b. Tell the patient to continue to take the drug up to the day before surgery. c. Ask the patient if he has any side effects from taking this drug supplement. d. Notify the anesthesia care provider since this drug may interfere with anesthetics. 4. A 17-year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which action would the nurse take?  a. Witness the patient signing the permit after the surgeon obtains consent. b. Call a parent or legal guardian to sign the permit since the patient is under 18. c. Notify the hospital attorney that an emancipated minor is consenting for surgery. d. Obtain verbal consent since written consent is not neces- sary for emancipated minors. 5. Which intervention would the nurse prioritize to aid a pre- operative patient in coping with the fear of postoperative pain? a. Inform the patient that pain medication will be available. b. Teach the patient to use guided imagery to help manage pain. c. Describe the type of pain expected after the patient’s surgery. d. Explain the pain management plan and the use of a pain rating scale. 6. A patient is scheduled for surgery requiring general anes- thesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. Which action would the nurse take? a. Tell the patient to come back tomorrow since he ate a meal. b. Have the patient void before giving any preoperative medication. c. Proceed with the preoperative checklist, including site identification. d. Notify the anesthesia care provider of when and what the patient last ate. 7. A patient who takes metformin 500 mg every morning for control of type 2 diabetes asks if she should take her medica- tion the day of surgery. Which recommendation would the nurse make? a. Skip her medication the day of surgery. b. Get instructions from the surgeon about medication adjustments. c. Take her usual morning dose at bedtime the night before surgery. d. Take her medication as usual with a sip of water in the morning. 8. Which preoperative considerations would the nurse plan for the care of an older adult? (Select all that apply.) a. Using only large-print educational materials. b. Speaking louder for patients with hearing aids. c. Recognizing that sensory deficits may be present. d. Providing warm blankets to prevent hypothermia. e. Teaching important information early in the morning. Answers: 1. d; 2. b; 3. a; 4. a; 5. d; 6. d; 7. b; 8. c, d Chapter 19 - Intraoperative Care LEARNING OUTCOMES 1. Describe appropriate attire for various areas of the perioperative department. 2. Outline the roles and responsibilities of surgical team members. 3. Prioritize needs of patients undergoing surgery. 4. Analyze role of a perioperative nurse in managing patients undergoing surgery. 5. Apply basic principles of infection prevention and aseptic technique in the operating room. 6. Recognize operating room safety measures related to patients, equipment, and anesthesia. 7. Describe various anesthesia techniques and common anesthesia drugs. KEY TERMS anesthesia care provider (ACP) anesthesiology epidural block general anesthesia local anesthesia malignant hyperthermia (MH) nurse anesthetist regional anesthesia spinal anesthesia Questions: 1. Which items would the nurse wear for proper attire in the semirestricted area of the surgery department? a. Street clothing b. Surgical attire and head cover c. Street clothing and shoe covers d. Surgical attire, head cover, shoe covers 2. Which activities might the nurse perform in the role of a scrub nurse during surgery? (select all that apply) a. Checking electrical equipment b. Preparing the instrument table c. Assisting with draping the patient d. Passing instruments to the surgeon and assistants e. Documenting activities occurring in the operating room 3. The nurse is caring for a patient undergoing surgery for a knee replacement. Which factors are critical to the patient’s safety during the procedure? (select all that apply) a. Universal protocol is followed. b. The ACP is an anesthesiologist. c. The patient has adequate health insurance. d. The patient’s family is in the surgery waiting area. e. The patient’s allergies are conveyed to the surgical team. 4. Which action is the nurse’s primary responsibility for the care of the patient undergoing surgery? a. Developing a patient-centered plan of nursing care b. Carrying out tasks related to surgical policies and procedure c. Ensuring that the patient has been assessed for safe administration of anesthesia d. Performing a preoperative history and physical assessment to identify patient needs 5. Which action would the nurse take when scrubbing at the scrub sink? a. Scrub from elbows to hands b. Scrub without mechanical friction c. Scrub for a minimum of 10 minutes d. Hold the hands higher than the elbows 6. Which factors in positioning a patient for surgery increase the risk of patient injury? (select all that apply) a. Loss of pain perception b. Incorrect musculoskeletal alignment c. Vasoconstriction of the peripheral vessels d. Hypovolemia contributing to decreased perfusion e. Inability to sense pressure over bony prominences 7. Why is IV induction for general anesthesia the method of choice for most patients? a. The patient is not intubated. b. The agents are nonexplosive. c. Induction is rapid and controlled. d. Emergence is longer but with fewer complications.  Answers: 1. d; 2. b, c, d; 3. a, e; 4. a; 5. d; 6. a, b, d, e; 7. c. Chapter 20 - Postoperative Care LEARNING OUTCOMES 1. Prioritize nursing responsibilities related to managing patients in the postanesthesia care unit (PACU). 2. Prioritize nursing responsibilities to maintain patient safety and prevent postoperative complications in the PACU and clinical unit. 3. Apply data from the initial nursing assessment to the management of the patient after transfer from the PACU to the clinical unit. 4. Select nursing interventions to manage potential problems during the postoperative period. 5. Distinguish discharge criteria from Phase I and Phase II postanesthesia care. KEY TERMS airway obstruction atelectasis delayed emergence emergence delirium patient-controlled analgesia (PCA) postoperative ileus (POI) Questions: 1. Which actions would the nurse prioritize when admitting a patient to the PACU? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distention. c. Assess for airway patency and quality of respirations and obtain vital signs. d. Review results of intraoperative laboratory values and medications received. 2. A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse, “I think I am going to throw up.” Which is the priority intervention? a. Increase the rate of the IV fluids. b. Give antiemetic medication as ordered. c. Obtain vital signs, including O2 saturation. d. Position patient in lateral recovery position. 3. After admitting a postoperative patient to the clinical unit, which assessment data require attention first? a. O2 saturation of 85% b. Respiratory rate of 13/min  c. Temperature of 100.4°F (38°C) d. Blood pressure of 90/60 mm Hg 4. A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. Which interventions would the nurse prioritize? (Select all that apply.) a. Obtain a bladder ultrasound scan. b. Perform a straight catheterization. c. Continue to monitor this normal finding. d. Evaluate the patient’s fluid volume status. 5. Which factors would the nurse include in discharge criteria for a Phase II patient? (select all that apply) a. Nausea and vomiting controlled. b. Ability to drive themselves home. c. No respiratory depression present. d. Written discharge instructions understood. e. Opioid pain medication given 45 minutes ago. Answers: 1. c; 2. d; 3. a; 4. a, d; 5. a, c, d, e. Chapter 21 - Emergency and Disaster Nursing LEARNING OUTCOMES 1. Apply the steps in triage, the primary survey, and the secondary survey to a patient with a medical, surgical, or traumatic emergency. 2. Relate the pathophysiology to the assessment and interprofessional care of select environmental emergencies. 3. Relate the pathophysiology to the assessment and interprofessional care of select toxicologic emergencies. 4. Select appropriate nursing interventions for victims of violence. 5. Distinguish among the responsibilities of health care providers, the community, and select federal agencies in emergency and mass casualty incident preparedness. KEY TERMS drowning emergency frostbite heat exhaustion heatstroke hypothermia mass casualty incident (MCI) primary survey secondary survey submersion injury terrorism Triage violence Secondary Survey The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries (Table 21.5). It is helpful for discover- ing unknown problems in patients with a poor or confusing history.4,5 H = History and Head-to-Toe Assessment Obtain a history and mechanism of the injury or illness. These details provide clues to the cause and guide specific assessments and interventions. The patient may not be able to give a history. However, caregivers, friends, bystanders, and prehospital per- sonnel can often provide the necessary information. Use the memory aid “MIST” to help you obtain a prehospital report of the incident or illness: M: Mechanism of injury I: Injuries sustained S: Signs and symptoms before arrival T: Treatment before arrival Details of the incident are important because the mechanism of injury and injury patterns can predict specific injuries. For example, a restrained front-seat passenger may have knee or femur fractures from hitting the dashboard and a chest injury from the airbag. Those who fell off a ladder or roof may have fractures, spinal cord injury, or head trauma. SAMPLE is a memory aid that prompts you to ask about a patient’s history: S: Symptoms from the injury or illness A: Allergies (e.g., drugs, food, latex, environment) and tetanus status M: Medication history P: Past history (e.g., preexisting medical or psychiatric prob- lems, surgeries, smoking history, recent use of drugs or alco- hol, last menstrual period, baseline mental status) L: Last meal/oral intake E: Events or environmental factors leading to the illness or injury After you collect the patient’s history, a head-to-toe assess- ment completes the H part of the secondary survey. Note any abnormalities. Questions: 1. An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse’s next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the provider see him. d. determine the kind of insurance he has before treating him. 2. A patient has a core temperature of 90°F (32.2°C). The most appropriate rewarming technique would be a. passive rewarming with warm blankets. b. active internal rewarming using warmed IV fluids. c. passive rewarming using air-filled warming blankets. d. active external rewarming by submersing in a warm bath. 3. What interventions does the nurse anticipate for a patient with an aspirin overdose? (select all that apply.) a. Hemodialysis b. Corticosteroids c. Hyperbaric O2 d. Gastric lavage e. Activated charcoal 4. An older woman arrives in the ED reporting severe pain in her right shoulder. The nurse notes her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she “fell.” She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. Dementia b. Possible cancer c. Familyviolence d. Orthostatic hypotension 5. A chemical explosion occurs at a nearby industrial site. First responders report that victims are decontaminated at the scene, and about 125 workers will need medical evaluation and care. The first action of the nurse receiving this report should be to a. issue a code blue alert. b. activate the hospital’s emergency response plan. c. notify the Federal Emergency Management Agency (FEMA). d. arrange for the American Red Cross to provide aid to victims. Answers: 1.a; 2.b; 3.a,d,e; 4.c; 5.b. Chapter 26 - Burns LEARNING OUTCOMES 1. Relate the causes of burns to prevention strategies for burn injuries. 2. Distinguish between partial-thickness and full-thickness burns. 3. Apply tools used to determine the severity of burns. 4. Compare the pathophysiology, clinical manifestations, complications, and interprofessional care throughout the 3 burn phases. 5. Compare the fluid and electrolyte shifts during the emergent and acute burn phases. 6. Outline the nutrition needs of the burn patient. 7. Compare burn wound care techniques and surgical options for partial-thickness and full-thickness burn wounds. 8. Prioritize nursing interventions in the management of the burn patient’s physiologic and psychosocial needs. 9. Examine the physiologic and psychosocial aspects of burn rehabilitation. 10. Develop a plan of care to prepare the burn patient and caregiver for discharge. KEY TERMS chemical burns debridement electrical burns eschar escharotomy excision full-thickness burns inhalation injuries partial-thickness burns thermal burns  Pulse CO-Oximetry Monitoring Standard pulse oximetry (SpO2) does not distinguish oxyhemoglobin from carboxyhemoglobin. A patient with CO poisoning will have normal SpO2 readings despite high carboxyhemoglobin levels. For patients with suspected or in 16hrs confirmed CO poisoning, use a pulse CO oximetry (SpCO) device. Rule of 9 s Questions: 1. Which instruction would the nurse provide to prevent burn injuries? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended. 2. Which wound description indicates a need for excision and grafting? (select all that apply) a. Red, painful blisters b. Leathery, brown, exposed tendon c. Pearly white color, insensitive to pain, dry d. Charred eschar, visible thrombosed blood vessels e. Large, fluid-filled vesicles, moderate edema, moist, red 3. Estimate the total body surface area burn injury using the rule of 9’s. Burns involve the entire 18 right arm and upper back. _____% 4. A patient is hospitalized with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. The respiratory therapist applied a non-rebreather mask. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Respiratory rate is 6/min. Oxygen saturation decreases to 88%. The patient is unresponsive. What is the priority nursing intervention? a. Notify the HCP and get ready for intubation. b. Encourage the patient to cough and auscultate the lungs again. c. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. d. Document the findings and continue to monitor the patient’s breathing. 5. Which lab result supports the need for additional IV fluid to treat burn shock? a. Hematocrit 52% b. Sodium 137 mEq/L c. WBC 12.5 × 109/L d. Potassium 3.4 mmol/L 6. What nutrition intervention may promote wound healing for a patient with a 10% burn injury? a. Eat a high-protein, high-carbohydrate diet b. Increase normal caloric intake by about 4 times c. Eat at least 1500 calories/day in small, frequent meals d. Eat a lactose-free diet to reduce the potential for diarrhea 7. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. What is the most important nursing intervention following surgery? a. Wash the wound with soap and water 3 times a day. b. Medicate for pain relief in between dressing changes. c. Reapply a new dressing without disturbing the wound bed. d. Assess the wound for signs of infection during dressing changes. 8. What nursing interventions can be used to manage burn pain? (select all that apply) a. Suggest pain management options. b. Use a pain-rating tool to monitor the patient’s level of pain. c. Delay painful dressing changes until the patient’s pain is completely relieved. d. Use a multimodal approach (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. Provide nonpharmacologic therapies (e.g., music therapy, dis- traction) to replace opioids in the acute phase of a burn injury. 9. What intervention prevents hypertrophic scarring during the rehabilitation phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active ROM at least every 4 hours d. Applying a water-based moisturizer to healed skin 10. A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is plan- ning for discharge. The first action the nurse would take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. give the patient written information and websites resources for burn survivors.  c. teach the patient and the caregiver proper wound care to be performed at home. d. review the patient’s current health care status and readi- ness for discharge to home. Answers: 1. c; 2. b, c, d; 3. 18% 4. a; 5. a; 6. a; 7. d. 8. a; b, d; 9. a; 10. d. Chapter 28 - Supporting Ventilation LEARNING OUTCOMES 1. Identify airway clearance techniques that promote gas exchange. 2. Describe the indications for O2 therapy, including delivery methods and complications. 3. Explain the purpose, function, and nursing responsibilities related to chest tubes and chest drainage systems. 4. Identify the types of chest surgery and appropriate perioperative care. 5. Relate the important aspects of care for the patient receiving noninvasive ventilation. 6. Distinguish the indications for and modes of mechanical ventilation. 7. Select appropriate nursing interventions related to the care of an intubated patient. 8. Identify the steps involved in suctioning a patient with an oral endotracheal tube or tracheostomy. 9. Describe complications of mechanical ventilation and corrective actions to ensure optimal ventilation and safe patient care. 10. Describe the process of weaning from mechanical ventilation. 11. Select appropriate nursing interventions related to care of the patient with a new tracheostomy. 12. Outline the essential teaching needed for the patient with a permanent tracheostomy. KEY TERMS assist-control (AC) ventilation chest physical therapy (CPT) continuous positive airway pressure (CPAP) decannulation endotracheal (ET) tube extubation intubation mechanical ventilation negative pressure ventilation noninvasive ventilation (NIV) positive end-expiratory pressure (PEEP) positive pressure ventilation (PPV) pressure control (PC) ventilation pressure support ventilation (PSV) pressure ventilation pursed-lip breathing (PLB) synchronized intermittent mandatory ventilation (SIMV) thoracotomy tracheostomy volume ventilation weaning Questions: 1. Which technique would be most appropriate for a patient with mild COPD to promote airway clearance? a. Huff coughing b. Postural drainage c. Pursed lip breathing d. High-frequency chest wall oscillation 2. The major advantage of a Venturi mask is that it can  a. deliver up to 80% O2. b. provide continuous 100% humidity. c. deliver a precise concentration of O2. d. be used while a patient eats and sleeps. 3. In a spontaneously breathing patient, the nurse notes tidal- ing of the water level in the water-seal chamber of the chest tube drainage system. The nurse would a. continue to monitor the patient. b. check all connections for a leak in the system. c. raise the collection unit above the level of the heart. d. clamp the tubing at a distal point away from the patient. 4. After a left lower lobe lobectomy, an appropriate nursing measure is to a. position the patient prone every 2 hours. b. monitor the chest tube drainage and functioning. c. auscultate lung sounds frequently in the lower left lobe. d. administer IV fluid boluses to maintain blood pressure. 5. Which assessment finding concerns you most in a patient with pneumonia who is receiving noninvasive ventilation (Bi-PAP)? a. New onset of confusion to time and place b. Fine crackles on auscultation of affected lobe c. Patient asks to remove the mask for oral care d. HR: 98, RR: 16 bpm, BP: 110/60, SpO2: 93% 6. A patient with multiple gunshot wounds returns to the ICU from surgery. Vital signs are stable. They are making no spontaneous respiratory effort. Which mode of ventilation would be most appropriate? a. Assist control (AC) b. Pressure support (PS) c. Bi-level positive airway pressure (Bi-PAP) d. Synchronized intermittent mandatory ventilation (SIMV) 7. Nursing management of a patient with an oral ET tube would include a. maintaining ET tube cuff pressure at 35 to 40 cm H2O. b. routine suctioning of the ET tube at least every 2 hours. c. observing the patient for spontaneous respiratory effort and work of breathing. d. preventing ET tube dislodgment by limiting mouth care to lubrication of the lips. 8. Which nursing action would be the highest priority when suctioning a patient with an oral ET tube or tracheostomy? a. Hyperoxygenate with 100% FIO2 before suctioning. b. Auscultate lung sounds after suctioning is completed. c. Instill 5 mL of normal saline into the tube before suctioning. d. Give antianxiety medications 30 minutes before suctioning. 9. The nurse monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility. b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide.  c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels. 10. Which findings indicate the patient is ready for weaning from mechanical ventilation? (select all that apply) a. Serum hemoglobin of 15 g/dL b. Respirations of 18 breaths/min c. Patient is alert and follow commands d. Chest x-ray shows large pleural effusion e. Mean arterial pressure (MAP) of 55 mm Hg f. ABGS: pH 7.38, PaCO2 37 mm Hg, HCO3− 24 mEq/L, PaO2 94 11. Immediate care priorities in the first few hours for a patient with a new tracheostomy include a. encouraging early mobility. b. changing the tracheostomy ties. c. suctioning the tracheostomy hourly. d. observing for bleeding at the insertion site. 12. Appropriate discharge teaching for the patient with a per- manent tracheostomy after a total laryngectomy would include (select all that apply) a. encouraging regular exercise such as swimming. b. washing around the stoma daily with a moist washcloth. c. emphasizing the importance of regular follow-up appointments d. providing pictures and “hands-on” instruction for tracheostomy care. e. having a list of emergency contact numbers and where to obtain supplies. Answers: 1. a; 2. c; 3. a; 4. b; 5. a; 6. a; 7. c; 8. a; 9. c; 10. a. b, c, f; 11. d; 12. b, c, d, e. Chapter 44 - Nutrition Problems LEARNING OUTCOMES 1. Relate the components of a well-balanced diet to their impact on health outcomes. 2. Describe the etiology, clinical manifestations, and interprofessional and nursing management of malnutrition. 3. Describe the components of a nutrition assessment. 4. Explain the indications, complications, and nursing management related to the use of enteral nutrition. 5. Explain the indications, complications, and nursing management related to the use of parenteral nutrition. 6. Compare the etiology, clinical manifestations, and nursing management of eating disorders. KEY TERMS anorexia nervosa (AN) bulimia nervosa (BN) enteral nutrition (EN) malabsorption syndrome malnutrition parenteral nutrition (PN) refeeding syndrome tube feeding sorceresses Questions: 1. The percentage of daily calories for a healthy person consists of a. 50% carbohydrates, 25% protein, 25% fat, and 10% of fat from saturated fatty acids. c. 50% carbohydrates, 40% protein, 10% fat, and 10% of fat from saturated fatty acids. 2. Place in order the substrates the body uses for energy during starvation, beginning with 1 for the first component and ending with 4 for the last component. a. Skeletal protein b. Glycogen c. Visceralprotein d. Fat stores 3. A complete nutrition assessment including anthropometric measurements is most important for the patient who a. has a BMI of 25.5 kg/m2. b. reports episodes of nightly nocturia. c. reports a 5-year history of chronic constipation. d. reports unintentional weight loss of 10 lb in 2 months. 4. Which method is best to use when confirming initial place- ment of a blindly inserted small-bore NG feeding tube? a. X-ray b. Air insertion c. Observing patient for coughing d. pH measurement of gastric aspirate 5. A patient is receiving peripheral parenteral nutrition. The solution is completed before the new solution arrives on the unit. The nurse gives a. 20% intralipids. b. 5% dextrose solution. c. 0.45% normal saline solution. d. 5% lactated Ringer’s solution. 6. A patient with anorexia nervosa shows signs of malnutri- tion. During initial refeeding, the nurse carefully assesses the patient for (select all that apply) a. Hypokalemia. b. Hypoglycemia. c. hypercalcemia. d. hypomagnesemia. e. hypophosphatemia. Answers: 1. a; 2. b, a, d, c; 3. d; 4. a; 5. b; 6. a, d, e Chapter 67 - Musculoskeletal Trauma and Orthopedic Surgery LEARNING OUTCOMES 1. Discuss the etiology, pathophysiology, manifestations, and interprofessional and nursing management of soft tissue injuries. 2. Relate the sequence of events involved in fracture healing. 3. Compare closed reduction, casting, open reduction, and traction in terms of purpose, complications, and nursing management. 4. Assess the neurovascular condition of an injured extremity. 5. Explain common complications of a fracture and fracture healing. 6. Describe the interprofessional and nursing management of patients with various kinds of fractures. 7. Describe indications for and interprofessional and nursing management of the patient with an amputation. 8. Describe types of joint replacement surgery. 9. Prioritize management of the patient having joint replacement surgery. KEY TERMS amputation arthrodesis arthroplasty bursitis carpal tunnel syndrome (CTS) compartment syndrome debridement dislocation fat embolism syndrome (FES) fracture osteotomy phantom limb sensation repetitive strain injury (RSI) sprain strain traction Questions: 1. The nurse in urgent care suspects an ankle sprain when a patient describes a. being hit by another soccer player during a game. b. having ankle pain after sprinting around the track. c. droppinga10-lbweightonhislowerlegatthehealthclub. d. Twisting his ankle while running bases during a baseball game. 2. A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by a. formation of callus. b. complete bony union. c. hematoma at the fracture site. d. presence of granulation tissue. 3. A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the frac- ture. The nurse explains that ORIF is indicated when a. the patient cannot tolerate prolonged immobilization. b. the patient cannot tolerate the surgery for a closed reduc- tion. c. other nonsurgical methods cannot achieve adequate alignment. d. a temporary cast would be too unstable to provide normal mobility. 4. The nurse suspects a neurovascular problem based on assess- ment of a. exaggerated strength with movement. b. increased redness and heat below the injury. c. decreased sensation distal to the fracture site. d. purulent drainage at the site of an open fracture. 5. A patient with a stable, closed humeral fracture has a tempo- rary splint with bulky padding applied with an elastic ban- dage. The nurse suspects early compartment syndrome when the patient has a. increasing edema of the limb. b. muscle spasms of the lower arm. c. bounding pulse at the fracture site. d. pain when passively extending the fingers. 6. The nurse would monitor a patient with a pelvic fracture for a. changes in urine output. b. petechiae on the abdomen. c. a palpable lump in the buttock. d. sudden increase in blood pressure. 7. The nurse teaches the patient with an above-the-knee ampu- tation that the residual limb should not be routinely elevated because this position promotes a. hip flexion contracture. b. clot formation at the incision. c. skin irritation and breakdown. d. increased risk for wound dehiscence. 8. A patient with osteoarthritis is scheduled for total hip arthro- plasty. The nurse explains the purpose of this procedure is to (select all that apply) a. fuse the joint.  b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint. 9. A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid a. lifting heavy objects. b. sleeping on the back. c. abduction exercises of the affected ankle. d. bearing weight on the affected leg for 6 weeks. Answers: 1. d; 2. a; 3. c; 4. c; 5. d; 6. a; 7. a; 8. b, d; 9. d.