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Hesi rn medical Surg (managing care of adult)
Total Questions : 53
Showing 10 questions, Sign in for moreThe 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.)
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.
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)
Explanation
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.
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.
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Chief Complaint: Acute asthma attack after jogging; worsened by outdoor activity and exercise.
- Current Treatment: Used rescue inhaler three times, expired inhaler, worried about effectiveness.
- Temperature: 98.9°F (37.1°C) – Normal
- Heart Rate: 112 beats/minute – Elevated (tachycardia)
- Respirations: 28 breaths/minute – Elevated (tachypnea)
- Blood Pressure: 130/86 mm Hg – Normal
- Oxygen Saturation: 88% on room air – Low (hypoxemia)
- Lung Sounds: Expiratory wheezes – Indicative of asthma or bronchospasm
- Capillary Refill Time: 2 seconds – Normal
Patient Data
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 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.
Initial Assessment
Temperature 98.9" F (37.1" C).
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg.
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed
Patient Data
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.
Tola: a,b,c,e ~ 4mos ago
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.
Patient Data
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.
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.
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.
Patient DataThe nurse has Implemented additional needed actions.
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.
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.
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 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use recreational drugs. Typically, he drinks 2 to 3 dark beers nightly.
The healthcare provider is considering medications to treat the client's gout.
Patient Data
For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.
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.
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Day 1, 1130
Serum uric acid
9.1 mg/dL (0.54 mmol/L)
4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L)
Blood urea nitrogen
18 mg/dL (6.43 mmol/L)
Reference range
10 to 20 mg/dL (3.6 to 7.1 mmol/L)
Creatinine
0.9 mg/dL (80 μmol/L)
Reference range
0.6 to 1.2 mg/dL (53 to 106 μmol/L)
Patient Data
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
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.
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Tola: A,B,C,D ~ 4mos ago