Systems of Care 3 Med-Surg Practice Questions (Exam 1)

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1. When assessing a patient's nutritional-metabolic pattern related to hematologic health, the nurse would A. B. C. D. Inspect the skin for petechiae. Ask the patient about joint pain. Assess for vitamin C deficiency. Determine if the patient can perform ADLs.

A: Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. 2. When assessing lab values on a patient admitted with septicemia, the nurse would expect to find A. B. C. D. Increased platelets. Decreased red blood cells. Decreased erythrocyte sedimentation rate (ESR). Increased bands in the white blood cell (WBC) differential (shift to the left).

D: When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity, with the less mature forms on the left side of a written report. Hence, the term shift to the left is used to denote an increase in the number of bands. 3. Results of a patients most recent blood work indicate an elevated neutrophil level. You recognize that this diagnostic finding most likely suggests A. B. Hypoxemia. An infection.

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C. D. A risk of hypocoagulation. An acute thrombotic event.

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B: An increase in neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

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4. A 30-year-old patient has undergone a splenectomy as a result of injuries suffered in a motor vehicle accident. Which of the following phenomena is likely to result from the absence of the patients spleen (select all that apply)? A. B. C. D. E. Impaired fibrinolysis Increased platelet levels Increased eosinophil levels Fatigue and cold intolerance Impaired immunologic function

B, E: Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen. 5. You are providing care for older adults on a subacute, geriatric medicine unit. Which of the following effects is aging likely to have on hematologic function of older adults? A. B. C. D. Hypercoagulability Decreased hemoglobin Decreased blood volume Decreased WBC count

B: Older adults frequently experience decreased hemoglobin levels as a result of changes to erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in coagulation are not considered to be normal, age-related hematologic changes. 6. A blood type and cross-match has been ordered for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. This means that A. B. The patient has A antigens on his red blood cells (RBCs). The patient may only receive a type A transfusion.

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C. D. The patient can be transfused with type AB blood. Antibodies are present on the surface of the patients RBCs.

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A: An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O.

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7. The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurses response is based on the knowledge that which of the following is a diagnostic criterion for AIDS? A. B. C. D. Presence of HIV antibodies CD4+ T cell count <200/l White blood cell count <5000/l Presence of oral hairy leukoplakia

B: Diagnostic criteria for AIDS include a CD4+ T-cell count <200/l and/or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease, but do not define the advancement of the disease to AIDS. 8. When teaching a patient infected with HIV regarding transmission of the virus to others, which of the following statements made by the patient would identify a need for further education? A. B. C. D. gym. A: HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat. 9. A hospital has seen a recent increase in the incidence of hospital-acquired infections (HAIs). Which of the following measures should be prioritized in the response to this trend? A. B. C. Use of gloves during patient contact Frequent and thorough hand washing Prophylactic, broad-spectrum antibiotics I will need to isolate any tissues I use so as not to infect my family. I will notify all of my sexual partners so they can get tested for HIV. Unprotected sexual contact is the most common mode of transmission. I do not need to worry about spreading this virus to others by sweating at the

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D. Fitting and appropriate use of N95 masks

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B: Hand washing remains the mainstay of the prevention of HAIs. Gloves, masks, and antibiotics may be appropriate in specific circumstances, but none of these replaces the central role of vigilant, thorough hand washing.

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10. Standard precautions should be used when providing care for A. B. C. D. All patients regardless of diagnosis. Pediatric and gerontologic patients. Patients who are immunocompromised. Patients with a history of infectious diseases.

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A: Standard precautions are designed for all care of all patients in hospitals and health care facilities. 11. The nurse is providing care for a patient who has been living with HIV for several years. Which of the following assessment findings most clearly indicates an acute exacerbation of the disease? A. B. C. D. A new onset of polycythemia Presence of mononucleosis-like symptoms A sharp decrease in the patients CD4+ count A sudden increase in the patients WBC count

C: A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patients WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion. 12. The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which of the following abnormalities associated with this oncologic emergency? A. B. C. D. Hypokalemia Hypocalcemia Hypouricemia Hypophosphatemia

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B: TLS is a metabolic complication characterized by rapid release of intracellular

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components in response to chemotherapy. This can rapidly lead to acute renal failure. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.

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13. The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patients nutritional intake? A. B. C. D. Increase intake of liquids at mealtime to stimulate the appetite. Serve three large meals per day plus snacks between each meal. Avoid the use of liquid protein supplements to encourage eating at mealtime. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. D: The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat. 14. Which of the following items would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? A. B. C. D. Firm-bristle toothbrush Hydrogen peroxide rinse Alcohol-based mouthwash 1 tsp salt in 1 L water mouth rinse

D: A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. 15. Which of the following nursing diagnoses is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? A. B. C. D. Incorrect Acute pain Hypothermia Powerlessness Risk for infection

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D: Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.

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16. Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend? A. B. C. D. A bland, low-fiber diet Incorrect A high-protein, high-calorie diet A diet high in fresh fruits and vegetables A diet emphasizing whole and organic foods

A: Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often benefit from a diet low in seasonings and roughage. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea. 17. A 33-year-old patient has recently been diagnosed with stage II cervical cancer. The nurse would understand that the patients cancer A. B. C. D. Is in situ. Has metastasized. Has spread locally. Has spread extensively.

C: Stage II cancer is associated with local spread. Stage 0 denotes cancer in situ; stage III denotes extensive regional spread, and stage V denotes metastasis 18. The nurse preparing to administer a dose of Phoso to a patient with chronic kidney disease would interpret that this medication should have a beneficial effect on which of the following laboratory values of the patient? A. B. C. D. Sodium Potassium Magnesium Phosphorus

D: Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of

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calcium should help to reduce a patients abnormally high phosphorus level, as seen with chronic kidney disease.

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19. When caring for a patient during the oliguric phase of acute kidney injury, which of the following would be an appropriate nursing intervention? A. B. C. D. Weigh patient three times weekly. Increase dietary sodium and potassium. Provide a low-protein, high-carbohydrate diet. Restrict fluids according to previous daily loss.

D: Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention; hence, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 ml for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times a week. 20. Which of the following statements by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. B. C. D. It is essential that you maintain aseptic technique to prevent peritonitis. You will be allowed a more liberal protein diet once you complete CAPD. It is important for you to maintain a daily written record of blood pressure and weight. You will need to continue regular medical and nursing follow-up visits while performing CAPD. A: Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for mortality as does the peritonitis, thus making that nursing action of highest priority. 21. A patient with a history of end-stage renal disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which of the following assessments should the nurse prioritize before, during, and after his treatment?

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A. B. C. D. Level of consciousness Blood pressure and fluid balance Temperature, heart rate, and blood pressure Assessment for signs and symptoms of infection

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B: Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of procedure indicates a particular need to monitor patients blood pressure and fluid balance.

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22. A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. Which of the following is an expected assessment finding for this patient during this early stage of recovery? A. B. C. D. Hypokalemia Hyponatremia Large urine output Leukocytosis with cloudy urine output

C: Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention. 23. Which of the following assessment findings is a consequence of the oliguric phase of acute kidney injury (AKI)? A. B. C. D. Hypovolemia Hyperkalemia Hypernatremia Thrombocytopenia

B: In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI. 24. Which of the following statements made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. B. C. D. You will need to get rid of your pets. You should sleep in an air-conditioned room. You would do best to stay indoors during the winter months. You will need to dust your house with a dry feather duster twice a week.

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B: Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors.

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25. When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which of the following foods (select all that apply)? A. Grapes B. Oranges C. Bananas D. Potatoes E. Tomatoes C: Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. The most common of these foods are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots. 26. Ten days after receiving a bone marrow transplant, a patient has developed a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? A. B. C. D. The patient is experiencing a type I allergic reaction. An atopic reaction is causing the patients symptoms. The patient is experiencing rejection of the bone marrow. Cells in the transplanted bone marrow are rejecting the host tissue.

D: The patients symptoms are characteristic of graft-versus-host-disease (GVHD) in which transplanted cells mount an immune response to the hosts tissue. GVHD is not a type I allergic response or an atopic reaction, and it differs from transplant rejection in that the graft rejects the host rather than the host rejecting the graft. 27. A patients low hemoglobin and hematocrit have necessitated a transfusion of packed red blood cells (PRBCs). Shortly after the first unit of PRBCs is hung, the patient develops signs and symptoms of a transfusion reaction. Which of the following hypersensitivity reactions has the patient experienced? A. Type I

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B. C. D. Type II Type III Type IV

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B: Transfusion reactions are characterized as a type II (cytotoxic) reaction in which agglutination and cytolysis occur.

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28. A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patients immunotherapy, which of the following is the nurses priority action? A. B. C. D. Monitoring the patients fluid balance Assessing the patients need for analgesia Assessing the patient for changes in level of consciousness Monitoring for signs and symptoms of an adverse reaction

D: When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction. The high risk and significant consequence of an adverse reaction supersede the need to assess the patients fluid balance, whereas pain and changes in level of consciousness are not likely events when administering immunotherapy. 29. For which of the following individuals is genetic carrier screening indicated? A. B. C. D. A patient with a history of type 1 diabetes A patient with a family history of sickle cell disease A patient whose mother and sister died of breast cancer A patient who has a long-standing history of iron-deficiency anemia

B: Genetic carrier screening should be done in families with a history of sickle cell disease. Diabetes and iron-deficiency anemia are not amenable to any form of genetic testing, whereas a family history of breast cancer suggests the need for presymptomatic testing for estimating the patients risk of developing breast cancer. 30. A nurse interviews an older female patient who is complaining of progressive fatigue, shortness of breath, and headaches. What question should the nurse ask first to collect more data surrounding the possible cause of the patients symptoms? A. Do you have a history of liver or kidney disease? B. Can you tell me about your diet? C. Have you been feeling depressed lately?

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D. What medications do you routinely take?

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B. All are possible questions to ask a patient surrounding symptoms of fatigue, shortness of breath, and headaches. However, older patients are more likely to experience signs and symptoms of anemia (fatigue, shortness of breath, headaches) related to diet and chronically bleeding GI lesions (peptic ulcer disease).

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31. The patients hematologic assessment results are: Red blood cell count: 3.8 million/mm3 Hemoglobin: 10 g/dL Hematocrit: 30% MCV 85 fl (normal = 80-90) MCH 29 pg (normal = 27-31) MCHC 34% (normal = 34%) Retic 1%

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These results suggest that the patient may be experiencing: A. Chronic hypoxia B. Iron deficiency C. A liver disorder D. Hemorrhage D. The patients laboratory values are consistent with the presence of hemorrhage. Chronic hypoxia is unlikely because her red blood cell count is not elevated. Liver disorder is unlikely because her iron level is actually slightly low. The patients laboratory values are not consistent with the presence of a malignancy. 32. The patient is complaining of increased fatigue, bleeding gums, and frequent chills. What is the most appropriate initial nursing intervention? A. Notify the physician of the patients complaints. B. Review the laboratory analysis for signs and symptoms of bone marrow suppression. C. Review the laboratory analysis for signs and symptoms of infection. D. Administer the prescribed antibiotics to manage the patients current infection. B. The nurse should initially review the patients laboratory analysis for collective signs of pancytopenia related to the patients complaints of fatigue (anemia), bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the physician and making the decision to administer or not administer an antibiotic.

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33. The patient was transitioning from IV heparin therapy to oral warfarin/coumadin. Therapeutic anticoagulation of the patient is best assessed by: A. Partial thromboplastin time of 24.3 seconds B. Prothrombin time of 18 seconds C. International normalized ratio of 2.5 D. Bleeding time of 5 minutes C. International normalized ratio (INR) is a more accurate measure of anticoagulation therapy because of variations in prothrombin time (PT) values across different laboratories. The goal on warfarin therapy is usually to maintain the patients INR between 2.0 and 3.0 regardless of the actual PT in seconds.

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34. After obtaining a patients blood pressure, you notice petechiae upon removal of the blood pressure cuff. What should be the nurses priority intervention? A. Obtain a blood sample to assess the patients coagulation status. B. Ask the patient about a history of bleeding disorders. C. Ask the patient about medications he is currently taking. D. Ask the patient if he is experiencing bone, sternum, or rib pain. B. The priority question would be to see if the patient has a past medical history or family history of bleeding disorders, difficulty with bleeding, etc. A second priority question would be to assess what medications he is currently taking that may increase bleeding time as a cause of the petechiae. Bone pain is a sign of hematologic disease and baseline coagulation studies are needed in treatment of the patient, but these data points can occur safely after obtaining a more detailed patient history. 35. While reviewing the results of a 76-year-old patients complete blood count (CBC), which of the following findings would be of most concern to the nurse? A. Platelets of 400,000/L B. Hemoglobin of 11.4 g/dL C. White cell count of 3000/L D. Red cell count of 4.5 106/L C. A white blood cell count of 3000/L is low (leukopenia); the patient is at risk for infection. The hemoglobin is low but is not at a critical level. The platelet count and red blood cell count are within normal range. 36. What type of transfusion reaction would the patient who received multiple transfusions over the course of his cancer treatment most likely experience? A. Febrile B. Bacterial C. Allergic D. Hemolytic

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A. A febrile transfusion reaction occurs most often in the patient with anti-WBC

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antibodies, a situation that can develop after multiple transfusions. Bacterial transfusion reactions occur as a result of infusing contaminated blood products. Allergic transfusion reactions are most often seen in patients with a history of allergy. Hemolytic transfusion reactions are caused by a blood type of Rh incompatibility.

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37. A 23-year-old African-American male with a history of sickle cell disease had an emergent open reduction and internal fixation (ORIF) of his right femur after a car crash. What is the initial postoperative nursing priority? A. Ensuring adequate IV hydration B. Treating the patients pain C. Titrating oxygen for an SaO2 of 88-92% D. Examining the surgical incision for signs and symptoms of infection A. Anesthesia and stress can precipitate a sickle cell crisis. Adequate hydration is a priority postoperatively to support vital signs, as well as treat sickle cell symptoms and sickle cell associated pain. Effective hydration will augment additional pain management strategies necessary for treating sickle cell pain and postoperative pain management. Ensuring adequate oxygenation is also important because hypoxemia initiates or worsens sickling of cells but higher SaO2 is required. 38. What is a priority nursing intervention in the care of an older patient with a history of gastritis and pernicious anemia? A. Encouraging a diet high in vitamin B12 B. Preventing falls C. Turning the patient every 2 hours D. Monitoring intake and output B. The patient will have difficulty absorbing vitamin B12 because of her diverticular disease and may have developed paresthesia in her feet, increasing the risk for falls. Preventing falls is a priority intervention in the care of older patients. 39. At an outpatient clinic, a 78-year-old woman is found to have a Hb of 8.7 g/dL and a Hct of 35%. Based on the most common cause of these findings in the older adult, the nurse collects information regarding A. A history of jaundice and black tarry stools. B. A 3-day diet recall of the foods the patient has eaten. C. Any drugs that have depressed the function of the bone marrow.

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D. A history of any chronic diseases such as cancer or renal disease.

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D. A common cause of anemia in the older adult population is co-morbid conditions such as cancer or renal disease. 40. A patient is receiving platelet transfusions for treatment of acquired thrombocytopenia. To detect the development of a platelet transfusion reaction, the nurse monitors the patient for A. Flushing, itching, and urticaria. B. Sudden onset of chills and fever. C. Urticaria, wheezing, and hypotension. D. Tachycardia, tachypnea, and hemoglobinuria. B. Febrile nonhemolytic reactions are caused by leukocyte incompatibility; sensitization to donor platelets may cause sudden chills and fever.

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41. Patients who have not been taking opiods regularly are referred to as A. Opiod tolerant B. Opiod nave C. Opiod free D. Sober

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B. Opioid nave patients are those who have not been taking opioids regularly. Most surgical patients and trauma victims would be considered as opioid nave. Patients are at a greater risk for respiratory depression, so nurses should consider continuous pulse oximetry, especially in the pediatric population. 42. RNs may A. Initiate a PCA infusion B. Change the PCA syringe C. Bolus via the PCA pump D. All of the above D. Two RNs must perform and document double checks and verify orders per medication policy when initiating or changing administration of PCA medications. The RN may have a physicians order to give a bolus. This is a legitimate bolus and should not be confused with pushing the patients control button, which only the patient can do. 43. When initiating or changing doses in the PCA pump the RN may accomplish this independently with a physicians order. A. T B. F B. Two RNs must perform and document double checks and verify orders per medication policy when initiating or changing administration of PCA medications. 44. A 14 yo has a PCA pump. Who may operate the pump to administer incremental doses to this patient?

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A. The patients parents B. The patients legal guardian C. The patient D. All of the above C. Only the patient, including children, are to administer the incremental/bolus doses. Staff who become aware of PCA supplementation by anyone other than the patient should report this to the physician and document clearly.

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45. Any unused medication remaining in the PCA pump should be wasted and witnessed like any other narcotic waste A. T B. F A. Any unused medication remaining in the PCA pump should be wasted, witnessed by another licensed nurse, and documented per medication policy. 46. Side effects to monitor when a patient is on PCA therapy include A. Nausea, vomiting B. Pruritis C. Sedation, respiratory depression D. All of the above D. Side effects of opioids include constipation (most common), nausea, vomiting, pruritis, sedation, and respiratory depression (most serious). Sedation often precedes respiration depression.

47. The nurse should assess rate, depth and rhythm of respirations while the patient is asleep because A. Patients on PCA therapy are at risk for nocturnal hypoxia B. Nocturnal hypoxia can only be assessed while patient is sleeping C. Both A and B D. None of the above C. Nocturnal hypoxia is a risk for patients on PCA therapy. The nurse should assess the patients rate, depth, and rhythm of respirations while the patient is asleep. Patients with induced respiratory depression or over sedation may easily be stimulated to a higher level of consciousness and an increased respiratory rate, providing false sense of security.

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48. Monitoring the sedation score of patients receiving PCA therapy is vital because sedation often precedes respiratory depression. A. T B. F A. Sedation scores can be calculated using the Ramsey Sedation Scale or the Richmond Agitation-Sedation Scale (RASS). Respiratory assessment includes respiratory rate and depth, oxygen saturation, and skin and mucous membrane color assessment.

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49. After initiation of PCA therapy with a basal infusion, oxygen saturation should be monitored: A. Continuously for first 24 hours B. At least every 4 hours after first 24 hours C. hour after any order change D. All of the above A. Since basal infusion increases the risk of developing respiration sedation, continuous pulse oximetry monitoring for the first 24 hours of therapy is indicated for safety.

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