Hesi rn medical Surg (managing care of adult)

Question 1: View

The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on botom.)

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath. B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Explanation

A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.

This client has the highest priority, as he or she may be experiencing an acute asthma atack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

Question 2: View

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

A. Remove the medication from the dispensing system. B. Compare the client’s wristband to the medication administration record. C. Document administration of the medication. D. Open the medication package. E. Obtain the client’s apical heart rate.

Explanation

Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.

Question 3: View

Patient Data

History and Physical

A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath B. The client reports that symptoms seem worse when outdoors and when exercising C. episodes like this make him extremely nervous D. it has been a couple of months since he had an asthma attack E. noticed that his inhaler was expired and was worried the medication was not working

Explanation

Subjective data refers to the symptoms reported by the client while objective data refers to the information collected on assessment of the client. During asthmatic attack, the client reports of shortness of breath, audible wheezing, inability to speak in complete sentences and a feeling of nervousness.

The use of a reliever without relief during an asthmatic attack indicates the severity of the attack. This requires intervention including the introduction of inhaled corticosteroids to reduce airway inflammation and remodeling.

The recurrence of symptoms on exposure to exercise requires the need for further advise to avoid triggers and recurrence of symptoms.

Question 4: View

Patient Data

Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions.

Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

A. Administer medications as ordered. B. Provide client teaching. C. Place the client in Trendelenburg position D. Ask the client for a list of current medications. E. Notify the healthcare provider of the client's need for intubation F. Apply oxygen via nasal cannula

Explanation

A The use of short acting beta agonists and oral steroids is key during an asthmatic attack to prevent respiratory failure.
D The nurse should also rule out the use of medications such as beta blockers which may predispose to asthmatic attack due to bronchospasms.
F Oxygen therapy should be initiated to prevent hypoxemia due to impaired ventilation. At this point, intubation may not be necessary until first line interventions have been attempted.
B Client teaching on proper inhalation technique is key. The client should also be advised on avoidance of triggers to prevent recurrence of the asthmatic attack. This, however, should be done after the client is stabilized.

Incorrect;

The Trendelenburg position is not recommended. Instead, sitting upright or in a semi-upright position can help expand the chest and improve lung expansion. This position allows the diaphragm to move more freely and can facilitate easier breathing. Leaning forward slightly may also help reduce the feeling of chest tightness.

Question 5: View

Patient Data

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which action(s) should the nurse take next? Select all that apply.

A. Administer additional nebulizer treatment as ordered. B. Take and monitor vital signs. C. Apply a nonrebreather oxygen mask. D. Increase oxygen flow. E. Raise the head of the bed. F. Provide client incentive spirometer and instruct on use.

Explanation

Inhaled short acting beta agonists can should be administered up to 3 times until there the obstruction in managed. In the event that the nebulization fails to relieve the respiratory distress, other treatment options such as magnesium sulphate can be used.

Oxygen flow should also be titrated appropriately to achieve the targeted SPO2 levels. However, changing the modality of oxygen delivery is not necessary at this part.

Continuous vital signs monitoring allows for timely interventions at all times to prevent respiratory failure. Although not a primary measure, raising the head of the bed can increase comfort reducing the work of breathing.

While incentive spirometry may have a role in the management of asthma in certain situations, such as during the recovery phase after an acute exacerbation or in individuals with chronic asthma who have reduced lung function, it is not typically used as a primary intervention during the acute phase of an asthma attack.

Question 6: View

Patient Data

Exhibits

The nurse performs an initial focused assessment of the client.

Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

A. Blood pressure 130/86 mmHg B. Respirations 28 breaths/minute C. Temperature 98.9" F (37.1°C) D. Heart rate 112 beats/minute E. Oxygen saturation 88% on room air

Explanation

In an asthmatic attack, exposure to triggers leads to bronchospasm which blocks airflow leading to impaired ventilation that manifests as respiratory distress- tachypnea. This prevents oxygenation with resultant hypoxia as evidenced by low SPO2 levels. Continuous use of a non- selective beta agonists leads to elevated heart rate.

Acute asthmatic attacks are not associated with changes in blood pressure

Acute asthmatic attacks are not associated with changes in temperature. However, when triggered by pulmonary infections, the client may experience episodes of fever.

Question 7: View

Patient DataThe nurse has Implemented additional needed actions.

Exhibits

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

A. Lung sounds clear B. Client can now speak in full sentences without pausing C. Respirations 16 breaths/minute D. Client reports, "It's a lot easier to breathe now." E. Blood Pressure 122/84 mmHg

Explanation

Short-acting beta agonists (SABAs) are a type of bronchodilator medication commonly used to relieve the symptoms of an asthmatic attack. When inhaled, SABAs act quickly to relax the smooth muscles in the airways, which helps to open up the air passages and improve airflow to the lungs. This rapid bronchodilation can alleviate symptoms such as wheezing, coughing, chest tightness, and shortness of breath, providing immediate relief during an asthma exacerbation.

Question 8: View

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

A. Administer pain medication at designated Intervals around the clock. B. Assess the pulses proximal to the fracture site. C. Remove traction every shift and provide skin care. D. Assess the pin sites for signs of infection.

Explanation

D. Pins or wires are often inserted into the bone to apply traction, and these insertion sites provide a potential route for infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, warmth, or drainage. Early detection and treatment of pin site infections help prevent the spread of infection and promote healing.
A. Administer pain medication at designated intervals around the clock:
While pain management is important for a client with a fracture, the primary intervention for skeletal traction is not necessarily related to pain medication administration.
B. Assessing pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this intervention is more relevant to vascular assessment and may not be directly related to skeletal traction.
C. Skeletal traction is typically maintained continuously to provide consistent traction and promote proper alignment of the fractured bone. Removing traction every shift would disrupt the therapeutic effect and delay healing.

Question 9: View

Patient Data

Exhibits

For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.

A. Colchicine B. Naproxen C. Prednisone D. Allopurinol

Explanation

Colchicine is used in severe acute gout attack to minimize pain at the joint. Colchicine's mechanism of action involves interfering with the inflammatory process by binding to tubulin, a protein essential for the formation of microtubules within cells.

Prednisone is a corticosteroid with anti-inflammatory properties. It reduces inflammation caused by urate crystals.

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). It interferes with the inflammatory process in gout reducing pain. The use of naproxen and prednisone with alcohol reduces their effectiveness leading to suboptimal pain relief.

Allopurinol is a lipid lowering agent. It prevents the formation of uric acid lowering the deposition of urate crystals at the joint(s). Missing a dose of allopurinol leads to subtherapeutic blood levels and increased risk of acute gout attacks.

Question 10: View

Patient Data

Exhibits here

The healthcare provider places orders to determine the extent of the client condition. Drag from Word Choices to complete the sentence.

Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for

and
dropdown
in his affected joint.

Explanation

Inflammation and discoloration are key symptoms of an acute gout attack.

Inflammation: This occurs when urate crystals in the joints trigger an immune response, causing swelling, redness, warmth, and significant pain.
Discoloration: Typically presents as redness over the affected joint, due to increased blood flow and inflammation, highlighting the body's response to the crystal deposits.

These symptoms help healthcare providers identify and treat gout, focusing on reducing inflammation and managing uric acid levels.