EXAM 1 Med Surg Flashcards
The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit?
Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask
RATIONALE: The charge nurse would assign the asthma client to the float pediatric nurse. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.
Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population. Although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.
The nurse is caring for a client who has had a lobectomy and placement of a chest tube 8 hours ago. When performing an initial assessment, which of these requires immediate follow up?
200 mL red drainage from chest tube over 2 hours
RATIONALE: The nurse must immediately report 200 mL of red drainage over a 2 hour span of time. Chest drainage should slow down after surgery. More than 70 mL of drainage/hour must be reported to the surgeon.
A client who had a surgical procedure, anesthesia, and analgesia may spend most of the day sleeping, but should be able to be aroused. A small amount of drainage after surgery is expected, such as a 3 cm area. The nurse should circle the area and report increasing amounts to the surgeon. Pain at the surgical and chest tube insertion site is expected and will be managed by the nurse in collaboration with the provider after airway, breathing, and circulation are ensured.
A client has just been admitted to the intensive care unit after having a left lower lobectomy via video-assisted thorascopic surgery. Which of these prescriptions will the nurse implement first?
Titrate oxygen flow rate to keep O2 saturation at or greater than 93%
RATIONALE: Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important.
Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important, but is secondary to airway, breathing, and circulation. PRBCs to maintain the oxygen-carrying capacity of the blood will be performed after oxygenation. Pain medication and antibiotic administration will be performed last.
The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first?
Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min
RATIONALE: The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first.
The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a hospice client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.
A client with acute exacerbation of asthma has been admitted to the medical surgical unit for treatment. The client is reporting increased shortness of breath with inspiratory and expiratory wheezes. When planning care for this client, which medication will the nurse administer first?
Albuterol-2 inhalations
RATIONALE: The nurse first needs to administer Albuterol, which is a rescue medication, to treat the client with increased shortness of breath with inspiratory and expiratory wheezes. Albuterol is a rapidly acting beta2 agonist that promotes bronchodilation.
Fluticasone is a corticosteroid and needs to be given after a bronchodilator is given to open the airways. It is used to prevent asthma attacks by decreasing airway inflammation, and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation. It is not immediately effective like a short acting a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time and is not used as a rescue medication.
The nurse is providing education to a client with chronic bronchitis who has a new prescription for a mucolytic. Which of these will the nurse teach the client about the purpose of the medication?
Mucolytics thin secretions, allowing for easier expectoration
RATIONALE: Client with chronic bronchitis typically produces large amounts of thick mucus interfering with gas exchange. Mucolytic means “breaking down mucus,” resulting in thinner secretions which are easier to expectorate.
Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange as secretions are cleared, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.
When caring for the client with chronic bronchitis, which of these interventions will assist the client in mobilizing secretions?
consume at least 2 liters of fluid daily
RATIONALE: Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 liters of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. The goal is to consume fluid to thin secretions and perform controlled coughing. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.
Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.
he nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover?
Hypercalcemia
RATIONALE: Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of cancer as well as bone metastasis. Bone metastasis should be suspected in the presence of back pain.
Paraneoplastic syndromes are manifested by Cushing’s syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria.
The nurse is educating the client with COPD who requires home oxygen therapy for discharge. Which of these teaching points takes the highest priority?
Removing combustion hazards present in the home
RATIONALE: The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use.
The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client’s oxygenation status and the visiting nurse or respiratory therapy partner can assess this. The client needs to be able to state the signs and symptoms of hypoxemia and when to notify the health care provider.
The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia. The nurse recognizes that a positive outcome to therapy has been achieved by which of these findings?
The oxygen saturation is between 88% and 90%
RATIONALE: Clients with hypoxemia, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.
Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level; hypoxemia may still be present. Flushing of the face can be a symptom of hypercarbia. A report of less distress is appropriate. The nurse, in any case, needs to use an objective measure of oxygenation such as pulse oximetry or blood gas results.
The nurse on a medical surgical unit is planning bed assignments for a new admission who has cystic fibrosis (CF) and is infected with Burkholderia cepacia. Which of these room assignments is most appropriate for this client?
A private room with a bathroom
RATIONALE: The most appropriate room for this client is a private room and separate bathroom. This provides maximum protection from organisms which can easily cause infection in the client with CF. A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. To reduce spread of infection, measures include separating infected CF clients from noninfected CF clients on hospital units and seeing them in the clinic on different days.
Laminar air flow is used in operating rooms and other areas where removing circulating air will provide for infection prevention. This is not required for those with CF. A client with Down syndrome may be unable to be careful with covering the mouth when coughing, using tissues, and handwashing, and would not be cohorted with a client who has high risk for infection.
When caring for a client who had a lobectomy the nurse notes small bubbles in the water seal chamber of the disposable chest drainage device during coughing. Which of these reflects the appropriate action by the nurse?
Document the finding in the medical record
RATIONALE: The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client’s exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.
Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.
After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse’s instructions?
“I must have my emergency inhaler with me at all times.”
RATIONALE: The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times. Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol).
Asthma medications are specific to the disease and to the client and should never be shared or used by anyone other than the person for whom they are prescribed. They are not always good for everyone and, in fact, may do harm. An emergency inhaler should be carried all the time and not just when activity is anticipated. Preventive drugs are those that are taken every day to help prevent an attack from occurring, and do not stop an attack once it begins.
The client says, “I hate this stupid COPD.” What is the best response by the nurse?
“You sound fed up with managing your illness.”
RATIONALE: The best response by the nurse is “You sound fed up with managing your illness.” This response encourages the client to express his or her feelings about the disease and its challenges.
Lecturing the client regarding his smoking habits disregards the client’s need for support. “Why” questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. Asking the client if anyone in the family has COPD is a “yes” or “no” question and does not encourage the client to talk about his or her feelings. The client’s feelings should never be minimized.
Which statement by a client with chronic obstructive pulmonary disease (COPD) and a 10 pound (4.5 kg) weight loss indicates the need for additional follow-up instruction?
“I should consume plenty of fluids with my meal.”
RATIONALE: The need for additional follow-up instruction is noted when the client states that he or she will drink more fluids before and during meals. This action will cause a sensation of fullness and limit adequate nourishment.
Eating smaller, more frequent meals, trying to eat more protein, and performing mouth care before eating are all appropriate and positive client comments.
The nurse is assessing a client admitted with status asthmaticus. The nurse finds a sudden absence of wheezing in the lung fields and sets which of these as the priority action?
Activation of the rapid response team to secure an airway
RATIONALE: Sudden absence of wheezing in a client having an asthma attack indicates complete airway obstruction and requires immediate action; a tracheotomy may be required.
This is an emergency and educating the client is not appropriate. A bronchodilator is given when breath sounds are present and the client can inhale. Reducing anxiety is not a consideration in an emergency situation.
The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion?
Cigarette smoking
RATIONALE: Cigarette smoking is highly addictive and is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease.
Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Cocaine use, while highly addictive, poses a risk for cardiovascular disorders such as ACS, MI, or stroke. Heroin use does not increase one’s risk of developing lung disease or lung cancer.
A client with COPD calls the pulmonary clinic reporting the last 24 hours the peak flow meter readings have been in the yellow range. Which of these interventions by the nurse is appropriate at this time?
Use your prescription for rescue medication and retest yourself
RATIONALE: The nurse would tell the client to use the rescue medication and then retest. This instruction by the nurse is appropriate. Reliever drugs (also called “rescue” drugs) are used to stop an attack once it has started or when the peak flow meter is in the yellow range or 50%–80% of personal best range.
The reading is not satisfactory. Frequent readings in the yellow zone indicate the need to reassess the asthma plan and the need to possibly change controller drugs. Satisfactory readings are in the green zone and are at least 80% of or better than the personal best readings. The client needs to seek care in the ED when the readings are in the red zone or below 50% of the personal best reading. Nurses do not prescribe medications or change dosing.
