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Vernon Watkins Vsim - 100% Correct Answers

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Question 1: The nurse knows that Vernon Watkins is most at risk for developing which of the following complications following a pulmonary embolism? Cardiogenic shock: the nurse must be alert for the... potential complication of cardiogenic shock or right ventricular failure subsequent to the effect of pulmonary embolism (PE) on the cardiovascular system Question 2: what initial objective and subjective data in Mr. Watkin’s case should lead the nurse to suspect a pulmonary embolism? Pain in the leg, resistance to ambulate – Vernon Watkin’s stated that he had a painful leg and he was refusing to ambulate this morning (immobility) increases the risk for stasis of blood, which may lead to a deep vein thrombosis in the calf with potential sequelae of pulmonary embolism (PE) should the clot be released and travel to the lungs Question 3: Vernon Watkins arterial blood gas results were reported as: pH 7.47, PaCO2 32 mmHg HCO3 mEq/L, PaO2 74 mmHg. How would the nurse best interpret these results? Respiratory alkalosis with mild hypoxemia – occurs when pH is greater than 7.45 and PaCO2 is less than 35 mmHg. Normal PaO2 is 80 to 100 mmHg, so a PaO2 reading below 80 mmHg indicates hypoxemia Question 4: A D-dimer assay was ordered. The nurse understands that which of the following is the purpose of this test? To detect evidence of clotting – D-dimer is a blood test used to screen thrombus formation Question 5: In patient who has had a hemicolectomy, the nurse would expect to find which type of bowel sounds four hours Post-op? Absent – patients undergoing bowel surgery will not have bowel sounds present in the immediate post op period. Decreased peristalsis occurs due to the effects of the anesthetic and analgesia and due to manipulation of the abdominal organs during surgery Question 6: Vernon was originally admitted through emergency with a diagnosis of bowel perforation. Complications can include peritonitis. Which is a hallmark sign of peritonitis that the nurse should assess? Diffuse pain with rebound tenderness – symptoms depends on the location and extent of inflammation. Over time the affected area of the abdomen becomes extremely tender and distended. Rebound tenderness will also develop Question 7: if Vernon developed oliguria, the nurse should assess which of the following lab values? Creatinine – an elevated creatinine level would indicate renal dysfunction. Hypoglycemia or hyperglycemia conditions would be assessed by a glucose level. Bicarbonate levels assess the state of acidosis or alkalosis. Creatine kinase is used in the diagnosis of MI’s, neuro disease or skeletal muscle disease Question 8: Vernon is receiving morphine for his pain. In addition to resp. depression, the nurse would monitor for what other adverse effect of this medication? [Show More]

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