A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment?
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Solution
X-ray the leg.
Following triage, an x-ray should be performed to rule out fracture. Ice, not heat, should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.
A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate for pain. Which of the following nursing actions is most important in the care of this patient?
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Solution
Monitor respiratory rate.
Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Morphine sulfate does not significantly affect urine output, heart rate, or body temperature.
A patient arrives at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?
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Solution
Hepatic damage.
Acetaminophen in even moderately large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.
A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?
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Solution
4 mcg/mL.
The therapeutic serum level for Dilantin is 10 – 20 mcg/mL. A level of 4 mcg/mL is subtherapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A level of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL, which is the incorrect unit of measurement.
An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased?
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Solution
Sudden weight gain.
Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. When diuretic therapy is inadequate, one would expect an increase in blood pressure, tachypnea, and tachycardia to result.
A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?
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Solution
Glucagon treats hypoglycemia resulting from insulin overdose.
Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
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Solution
A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge.
The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A postoperative patient also requires close monitoring and cardiac experience.
A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?
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Solution
If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family.
When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.
A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?
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Solution
The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.
It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.
A patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing action should take priority?
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Solution
Careful assessment of vital signs.
The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.