Respiratory Illness

A 55-year-old male patient with a history of lung cancer and pleural effusion is scheduled for a thoracentesis to drain fluid from the pleural space. Which of the following actions should the nurse take when prepping the patient for the procedure?

• Instruct the patient to fast for 12 hours before the procedure

• Administer a mild sedative to the patient before the procedure

• Position the patient sitting upright and leaning forward with arms supported

• Apply a warm compress to the puncture site after the procedure

Answer explanation

When prepping a patient for a thoracentesis, the nurse should position the patient sitting upright and leaning forward with arms supported. This position allows for optimal visualization of the puncture site and helps the patient breathe more easily during the procedure

A 40-year-old male patient has just undergone a lumbar puncture for the evaluation of his meningitis. Which of the following nursing interventions is appropriate for this patient post-lumbar puncture? Select all that apply

• Encourage the patient to lie flat for several hours to prevent headache

• Administer a bolus of IV fluids to prevent infection

• Monitor the patient for neurological changes and report any abnormalities to the healthcare provider

• Encourage the patient to resume normal activities immediately after the procedure

Answer explanation

After a lumbar puncture, the nurse should monitor the patient for neurological changes, such as headache, nausea, vomiting, or changes in vision, and report any abnormalities to the healthcare provider immediately. Headache is a common complication of lumbar puncture and can be caused by cerebrospinal fluid leakage from the puncture site.

Placing the client on his back and having him roll side to side reduces the risk of severe headache.

Administering a bolus of IV fluid can increase the risk of cerebral edema.

Do not Encourage the patient to resume normal activities immediately after the procedure , the patient may need to rest and limit physical activity for a period of time after the procedure to prevent complications.

A 65-year-old male patient has just undergone a femoral arteriogram to assess his peripheral vascular disease. Which of the following nursing interventions is appropriate for this patient post-procedure?

• Ambulate the patient immediately after the procedure to prevent complications

• Monitor the patient's affected leg for signs of bleeding or hematoma

• Instruct the patient to drink plenty of fluids to flush out the contrast dye

• Administer a prophylactic antibiotic to prevent infection

Answer explanation

APPLY A PRESSURE BANDAGE IMMEDIATELY AFTER the procedure

Explanation: After a femoral arteriogram, the nurse should monitor the patient's affected leg for signs of bleeding or hematoma, such as swelling, pain, and discoloration. Bleeding and hematoma are common complications of femoral arteriogram, and prompt intervention can prevent further complications. Ambulating the patient immediately after the procedure (A) is not recommended, as the patient may be at increased risk for bleeding and hematoma formation.

Instructing the patient to drink plenty of fluids to flush out the contrast dye is appropriate, but this is not the priority intervention in the post-procedure care of the patient.

A 50-year-old female patient with type 2 diabetes is scheduled for a renal function test that requires intravenous contrast dye. Which of the following nursing actions is appropriate regarding the patient's medication regimen?

• Hold the patient's insulin on the day of the test

• Hold the patient's metformin for 48 hours prior to the test

• Administer the patient's usual dose of metformin on the day of the test

• Administer the patient's usual dose of insulin on the day of the test

Answer explanation

Metformin can increase the risk of contrast-induced nephropathy, a potential complication of intravenous contrast dye administration. Therefore, the patient should hold metformin for 48 hours prior to the test to reduce the risk of this complication.

Insulin does not need to be held for the test, as it does not increase the risk of contrast-induced nephropathy.

The nurse is taking care of a 57 year-old patient that is scheduled to have a paracentesis. The nurse knows that she will have to ensure that which of the following actions occurs prior to the beginning of the procedure. Select all that apply

• Administering a painkiller to the patient

• Assisting the patient to void before the procedure

• Providing the patient with a meal before the procedure

• Place the patient in a sitting position

Answer explanation

Assisting the patient to void before the procedure is important for patient safety, especially in patients with a history of bladder dysfunction. Administering a painkiller may or may not be necessary depending on the patient's medical condition and pain level, but it is not a routine part of the procedure. Providing a meal before the procedure is not recommended, as the patient may need to fast before the procedure. Allowing the patient to eat or drink during the procedure is not recommended, especially in patients with a high risk of aspiration.

John, a 55-year-old male, underwent an EGD to investigate his longstanding heartburn symptoms. The nurse is concerned when he returns to the recovery room complaining of which of the following symptoms? Select all that apply

• Slight bleeding from the iv site

• Mild abdominal discomfort

• Difficulty swallowing

• Severe chest pain

• Shoulder pain

Answer explanation

Severe chest pain is concerning and should be immediately reported to the healthcare provider as it could be a sign of a complication such as a perforation. Shoulder pain is also a concerning sign and could indicate phrenic nerve injury or diaphragmatic irritation.

Minor complications include: Slight bleeding from the IV site may be common after the procedure and usually resolves on its own. Mild abdominal discomfort is also common and may be relieved with over-the-counter medications. Difficulty swallowing may be present immediately after the procedure but should not persist.

Match the following

• scant urine output

  < 30 ml/hr

• oliguria

• blood in the urine

• hematuria

• Excessive urine output

• polyuria

• no urine output

• anuria

Label the Chain of Infection in the correct order

b

a

c

d

e

f

Infectius agent

Portal of entry

Reservoir

portal of exit

mode of transmission

Supsceptibe host

The nurse is taking care of a patient with C-diff. Infection Control standards require that in addition to standard precautions ​ (a)  

• contact precautions must be implemented.
• droplet precautions must be implemented
• airborne precautions must be implemented
• neutropenic precautions must be implemented

When assessing the consensual reflex response in a patient, which of the following actions should the nurse perform?

• Touch the cornea with a cotton wisp

• Tap the patellar tendon with a reflex hammer

• Ask the patient to flex and extend their foot

• Shine a light in the patient's eye

Answer explanation

A)To assess the consensual reflex response, the nurse should shine a light in the patient's eye and observe the pupillary constriction in the opposite eye. This is known as the consensual response.

B)Touching the cornea with a cotton wisp is a test for corneal reflex.

C) Tapping the patellar tendon with a reflex hammer is a test for the knee-jerk reflex.

D)Asking the patient to flex and extend their foot is a test for the plantar reflex.