Reference no: EM133948845

Questions

1. What is the rationale for the nurse' s intervention in question 47?

a. Ambulation encourages deeper breaths and wider lung expansion.

b. Increase fluids liquefies secretions and aides in ease of expectorating sputum.

c. Including the patient in the plan of care improves opportunity for success.

d. Semi-fowlers position allows thoracic expansion and promotes respiratory gas exchange.

2. The physician orders 40% FiO2 for the patient with humidity. The nurse chooses which oxygen device:

a. Nasal Cannula

b. Non-rebreather mask

c. Simple face mask

d. Venturi Mask

CASE STUDY

L. Smith is a 27-year-old female admitted to the Emergency Department as a result of a road traffic accident. L.S. was alert and oriented to person, place, time on arrival. Vital signs - Temperature 98.6F (37C) Heart rate 89, Respirations 23, Blood pressure 120/ 70, oxygen saturation (Sa02) 97% on room air. An hour later while waiting to go to Radiology for a Computer Axial tomography (CT) Scan, the nurse notes L.S. is lethargic, slow to wake up, abdomen distended, firm with notable large bruising across the abdomen. The laboratory data revealed alcohol intoxication. The remainder of the lab data is in question 70. Updated vital signs, Temperature 100F (37.7C), Heart rate 120, pulse irregular, Respirations 26 quick and shallow, Blood pressure 90/ 55, oxygen saturation (Sa02) is 90% on room air. Skin is pale, cool, and clammy. The nurse inserts an intravenous (IV) cannula and starts 0.9% sodium chloride (normal saline) solution. Questions 67 - 70 refer to this case study.

3. The nurse administers an isotonic solution, 0.9% sodium chloride IV solution. What is the rationale for administering this solution?

a. Expand or replace extracellular fluid volume.

b. Decrease the amount of sodium Na+ in the blood.

c. Keep the blood pressure at the current level.

d. It is the only solution appropriate for this emergency.

4. A urinary catheter is inserted to closely monitor L.S. urinary output. In four (4) hours the patient received 600 ml of IV fluid and the urinary output was 50 mL in 4 hours, dark amber color. The nurse decides which condition is a priority for this client.

a. No bowel movement for 24 hours.

b. Respiratory rate 20 - 26.

c. Urinary retention

d. Urinary tract infection

5. The nurse continues to monitor the patient and notices cyanosis in the fingertips and toes. Oxygen saturation is 88% on room air. What is the nurse's next step?

a. Apply oxygen device to increase oxygen saturation to greater than 95%.

b. Continue to monitor oxygenation status with a pulse oximeter.

c. Elevate head of the bed to high fowlers position greater than 45 degrees.

d. Give the patient a blanket to warm the body.