final.docx - Adult II Final Study Guide 1.The nurse discusses management of upper respiratory infections(URI with a patient who has acute sinusitis

final.docx - Adult II Final Study Guide 1.The nurse...

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Adult II Final Study Guide 1.The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? “I can use my nasal decongestant spray until the congestion is all gone.” 2. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? Use a manometer to ensure cuff pressure is at an appropriate level. 3. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? The patient asks how to clean the tracheostomy stoma and tube. 4. After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? Clear nasal drainage. 5. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? Weak, nonproductive cough effort. 6. The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? Place patients with altered consciousness in side-lying positions. 7. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? The patient’s white blood cell (WBC) count is 9000/μL. 8. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? “My husband will be sleeping in the guest bedroom.” 9. A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? Explain that orange discolored urine and tears are normal while taking this medication. 10. After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? Ask the patient whether medications have been taken as directed. 11. The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? Options for smoking cessation. 12. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? Set up the patient- controlled analgesia (PCA) and administer the loading dose of morphine.
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13. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is
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  • Fall '17
  • Chronic obstructive pulmonary disease

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