Case Study 6, 7, 8, 9 Flashcards
COPD Paintent has a 99% Ox Sat with the help of 6L/min nasal canula. What is the nurses first intervention
What is the 2nd intervention
Remove oxygen canula
Goal is 90 - 94 Ox Sat in COPD.
Because High Ox can lead to Decreased Respitions which will Increase PCO².
2nd notify HCP
Home health care
Newly referred 70 yr with emphysema will need an initial visit today to evaluate the need for oxygen therapy. Which staff member is best to make initial home visit for the patient.
- Experienced LPN 10 years exp with home oxygen therapy
- Respiratory therapist who regularly works with homemade oxygen patients
- RN usually works Maternal, / child division of public health agency
- On-call RN works in home health agency a few days a month in her time off
- On-call RN works in home health agency a few days a month in her time off
Initial assessment is a job for an RN.
Chemotherapy (decreases / increases) ones ability to have a fetus
decreases: Decreased the WBC, so If there is a small fever whole neutral
May an experienced UAP ensure that the flow rate of a nasal canula is 5L/min
Yes, they can verify this
Ox Sat drops to 88% and resp is shallow 34/min
First action
Call HCP
Respiratory arrest is possible
ET intubation & Mechanical Ventilation required
High pressure alarm goes off on an Endotracheal Tube.
First action
If no actions are successful and alarm continues, what do you do?
Suction client of mucus.
Possible ausculate for crackles over trachea, this mean suction is needed.
If not successful: Manually vent while notifying respiratory therapist
Which do you preform before removing an ET tube?
- Set up oxygen delivery system
- Bring emergency equipment for reintubation to the bedside.
- Hyperoxygenate the client
- Rapidly deflate the cuff.
- Instruct client to cough while the tube is removed
- Adminster oxygen by face mask
- Set up oxygen delivery system
- Bring emergency equipment for reintubation to the bedside.
- Hyperoxygenate the client
- Rapidly deflate the cuff.
Which are in scope of practice of RN student nurse.
- Admin 50 mg of IV Ranitinde in 50 mL of NS to prevent gastric ulcers
- Monitor traction ropes and weights while the client is repositioned
- Assess neurological status for changes in movement & strength
- Provide pin site care using hydrogen peroxide & NS
- Adding a nursing concern to the care plan for the client at risk of infections
- Checking vital signs and oxygen sat
- Admin 50 mg of IV Ranitinde in 50 mL of NS to prevent gastric ulcers
- Provide pin site care using hydrogen peroxide & NS
- Checking vital signs and oxygen sat
Admin meds, simple treatments, adn VS
Bethanechol is prescribed for…
Urinary retention medication and Saliva production stimulator
Bladder retention training consists of SATA
- remove indwelling catheter
- Encourage client to limit fluid to 1000mL/day
3.Gradually increase intervals between Catheterization - Teach patient to initiate voiding by tapping on his bladder every 4 hours
- Teach to preform self-catheteruzation if necessary
- Adminster bethanechol chloride 20 mg orally 2x daily
- remove indwelling catheter
- Gradually increase intervals between catheterization
- Teach the patient to initiate voiding by tapping on his bladder every 4 hours
- Teach to perform self-catheteruzation if necessary
- Adminster bethanechol chloride 20 mg orally 2x daily
Mr.M is transferred to a rehabilitation facility. Which statement indicates that the client needs additional teaching.
- After rehabilitation, I may be able to achieve my goal of bladder function again.
- With rehab, I will regain all of my motor function
- Rehabilitation will help me to become as independent as possible
- After rehabilitation I hope to return to gainful employment.
- With rehab, I will regain all of my motor function
Read 2 or 3 times on real test.
You actually got this question wrong
3 major areas of concer for Addisons disease- Adrenal insufficiency
Hormone replacement
Hyperkalemia
Hypoglycemia
What action would the RN assign to an experienced LPN
- Interpret Ms. B’s lab values
- Change Ms B dressing on the right side
- Prepare a nursing care plan for Ms B
- Adminster IV promethazine for neausa
- Change Ms B dressing on the right side
IV drug administration is not Always in the LPNs role
But changing bandages is
With adrenal insufficiency (Addisons) HR (increase) 124, tremors, headache. Which action should the nurse take first.
- BS level
- Serum K
- Cardiac monitor
- Fluid restrictions
- BS level
Hypoglycemia
Common with Addisons
Biggest concern for Cushings disease.
- HR 102
- RR 26
- BP 156/88
- Temp 101.8
- Temp 101.8
Cushings = Over production of Cortisol (reduces # of circulating lymphocytes)
Greater risk for infection
Which factor supports Cushings Disease
- Cessation of menses at 33
- Increased craving for salty foods
- Weight loss 25 lbs
- Nausea Diarrhea, loss of appetite
- Cessation of menses at 33
Which happen with Cushings SATA
- Truncal obesity
- Weight loss
- Bruising
- Hypertension
- Thickened skin
- Dependent edema
- Truncal obesity
- Bruising
- Hypertension
- Dependent edema
Weight loss is expected with Addisons
Which will you find in Cushings (Excessive Cortisol Production) SATA
- Elevated serum cortisol
- Decreased serum sodium
- Elevated serum glucose
- Decreased lymphocytes
- Increased serum calcium
- Decreased urine androgen
- Elevated serum cortisol
- Elevated serum glucose
- Decreased lymphocytes
- Increased serum calcium
Not
2. Decreased serum sodium
6. Decreased urine androgen
Complete adrenalectomy nurse teachings about Cortisol replacement therapy. Include which key points
- Taken medication in 2 doses (1 upon waking & the other at 4 PM)
- Take meds on empty stomach to facilitate absorption
- Weight self daily
- Never skip dose of medication
- Call Dr.for persistent nausea, severe diarrhea, or fever
- Report any weight gain, round face, fluid retention, or swell to HCP.
- Taken medication in 2 doses (1 upon waking & the other at 4 PM)
- Weight self daily
- Never skip dose of medication
- Call Dr.for persistent nausea, severe diarrhea, or fever
- Report any weight gain, round face, fluid retention, or swell to HCP.
24 hr urine collection for vanillylmandelic acid, metanephrine, and catecholamine for Cushings syndrome
Which is not sure
- 2 - 3 day special diet is required before urine collection
- No caffeine, citrus fruits, bananas, or chocolate before test
- Continue taking all your regular meds, including aspirin & high blood pressure meds
- You will discard the first morning urine during the 24 hr urine collection
- Certain meds like Aspirin & Beta Blockers maybe stopped for the 24 hr urine collection test. BB due to rebound HTN
Which are interventions for Cushings when the candidate cannot receive an adrenalectomy?
- Admin spironolactone
- Monitor for and report Dry mouth, thirst, lethargy
- Avoid / Limit potassium rich food
- Gluccorticoid replacement therapy
- Instruct to report gynecomastia
- Acetaminophen for headache
- Admin spironolactone
- Monitor for and report Dry mouth, thirst, lethargy
- Avoid / Limit potassium rich food
- Instruct to report gynecomastia
- Acetaminophen for headache
- Gluccorticoid replacement therapy
Which nonpharmacological intervention for pain management is most appropriate for nephrolithiasis.
- Avoid over or underhydration
- Gentle back massage
- Darken room and encourage rest
- Apply ice pack to affected area
- Avoid over or underhydration
Balanced fluids makes kidney stones passage the least painful
renal calculi: reports that pain has decreased but is now having other symptoms. Which is most urgent
- Painless hematuria with small clots
- Dull pain that radiates to groin area
- Absence of pain amd scant urine output
- Scant urinary urgency
- Absence of pain amd scant urine output
Scant urine output = possible blocking the urine outflow. Which can damage the kidney
Other symptoms are common with renal calculi
Broken tibia which will relieve pain the most.
- Instruct to periodically move toes
- Diversional therapy
- Elevate injured leg above the heart
- Place in high fowler
- Elevate injured leg above the heart
This will minimize swelling. Swelling will put pressure on the nerves
Best time to activate PCA to receive dose of pain med
- When pain is 5 of 10.
- 30 min after waking and 30 minutes before bed
- As soon as lockout time expires, if pain is still present, even mild.
- 10 min before painful procedure (dressing change or PT)
- 10 min before painful procedure (dressing change or PT)
10 min is aprox time it takes for meds to kick-in.
5 maybe too much pain for an individual
Lockout Time must be explained but instruct patient not to focus dosage based on Lockout time
Tibia fracture. Reports new onset of right abdominal pain, hyperactive bowel sounds, tense abdomin and guarding and exquisite tenderness with palpation. Priority action.
- Give PRN pain med
- Notify HCP
- Take complete set of vitals
- Assist him to change posistion
- Take complete set of vitals
Measure vitals first then report to HCP.
RISK abdominal trauma
These findings represent a change
Status could be from internal bleeding
Assessment is 1st step in nursing process.
SBAR (to HCP) will require this information
After hernia repair surgery the patient is given dose of pain meds. 1 hr later the patient states they are still hurting. What is the first action
- Call HCP for a change in medication dose
- Initiate NPO incase surgery is needed
- Check bladder for distention and last voiding
- Reassure the patient that the hernia is not reoccurring
- Check bladder for distention and last voiding
Maybe experiencing bladder atony (bladder muscles can’t fully contract, difficult to empty the bladder)
What is the TENS unit used for?
Transcutaneous electrical nerve stimulation.
Decreases pain
Bacterial pneumonia pain management. Which can be Delegated to UAP?
- Clean TENS unit
- Notify nurse about patients request for pain meds
- Reinforce the use of pillow to splint cough
- Observe actions that increase fatigue
- Suggest relatives bring comfort items
- Assist patient in change posistion q2h
- Notify nurse about patients request for pain meds
- Reinforce the use of pillow to splint cough
- Assist patient in change posistion q2h
Not
1. Clean TENS unit (PTs Job)
4. Observe actions that increase fatigue (RNs job)
5. Suggest relatives bring comfort items (RN)
Peripheral inserted central catheter.
Following Meds & Solutions need to be given now.
Vancomycin 1.5 g in 250mL of 5% Dextrose over 90 min
Levofloxacin 750 mg in 150 mL NS over 90 min
5% Dextrose & 0.45% saline 1000mL with 20 mEq potassium at 125mL/hr
IV bolus of 3mg morphine
Priority action
- Call HCP & ask if meds times can be staggered
- Call pharmacy and inquire about compatibility of meds
- Give bolus of morphine first because it takes the least amount of time
- Obtain order to establish 2nd Peripheral IV site
- Call pharmacy and inquire about compatibility of meds
Call pharmacy first.
If not compatible give morphine first due to quick admin time.
If not compatible call HCP and inquire about staggering time or second line
Patient with substance abuse history who has bacterial pneumonia says; My back hurts bad. I need more morphine. Based on the principles of nonmaleficence what is the priority action.
- Believe his subjective report and give ordered pain meds.
- Contact HCP and request higher dose.
- Consider history of addiction, chronic pain, respiratory status and time of last dose.
- Offer nonpharmacological measures, ie. Posistion change.
- Consider history of addiction, chronic pain, respiratory status and time of last dose.
Nonmalifence means doing no harm to patient.
Consider factors such as Respitory Status with his bacterial pneumonia
Addiction is not a reason to withhold medicine, infact he may get a higher dose because of it.
Always review time of last dose given
Opiods are not typically first-line medication fir back pain.
Hospice patient son states: Assessment shows that patient has rapid shallow breathing and reports pain over right lateral ribs. What is priority action
- Take vitals / pulse ox and inform HCP
- Apply oxygen and raise HOB
- Obtain order and start IV for bolus morphine
- Be calm, stay with patient, encourage Pursed lip breathing.
- Apply oxygen and raise HOB
PRN oral morphine is typically prescribed for End-of-life care hospice patients
Hospice patients son complains that mother is not recieving enough pain meds. The HCP says “I’ll be in tomorrow. Just tell the son to deal with it.” Best action
- Call another HCP
- Continue with current orders
- Advise son to call HCP
- Notify unit manager
- Notify unit manager
Move up chain of command.
Calling another HCP is not appropriate