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Nursing VCE Exam_This 340 PAGE compilation contains Lesson 02 -Lesson 13

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Lesson 02 - Care of the Patient Experiencing Comorbid Conditions (Musculoskeletal and Endocrine) Due No due date Points 36 Questions 36 Time Limit None Attempt History Attempt Time Score LATEST ... Attempt 1 49 minutes 16.3 out of 36 ** Some questions not yet graded Score for this quiz: 16.3 out of 36 * Submitted Aug 13 at 12:36pm This attempt took 49 minutes. Question 1 1 / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 30 minutes to complete. Exercise 1 - Question 1 Which statements are true regarding the role and/or function of the endocrine and exocrine systems? Select all that apply. Endocrine glands are ductless glands. Exocrine glands are responsible for reproductive functioning. Endocrine glands release their secretions directly into the bloodstream. The endocrine system secretes hormones. Exocrine glands assist with maintaining homeostasis for the body. Question 2 1 / 1 pts Exercise 1 - Question 2 The [1] is considered the "master gland" of the endocrine system. Pituitary gland s pituitary gland Question 3 1 / 1 pts Exercise 1 - Question 3 [1] is the means by which the endocrine system maintains homeostasis. negative feedback s Negative feedback Question 4 0.8 / 1 pts Exercise 1 - Question 4 Match each disorder of the pituitary gland with its correct description. (A) A transient or permanent metabolic disorder of the posterior pituitary in which ADH is deficient (B) A disorder in which the pituitary gland releases too much ADH and, in response, the kidneys reabsorb more water (C) An overproduction of somatotropin in the adult (D) A condition in which there is a deficiency in growth hormone (E) A condition that usually results from an oversecretion of growth hormone Acromegaly C Gigantism E Dwarfism D Diabetes insipidus A Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) C B Question 5 Not yet graded / 1 pts Exercise 1 - Question 5 What is diabetes? A group of diseases that result in too much sugar in the blood high blood glucose. Diabetes is a disease that results when there is decreased activity of insulin, a decreased production of insulin, or an absolute lack of insulin being produced by the beta cells of the islets of Langerhans in the pancreas. Question 6 1 / 1 pts Exercise 1 - Question 6 For each characteristic listed below, identify whether it is a characteristic of (a) type 1 diabetes mellitus, (b) type 2 diabetes mellitus, or (c) both type 1 and type 2 diabetes mellitus. (A) Type 1 diabetes mellitus (B) Type 2 diabetes mellitus (C) Both type 1 and type 2 diabetes mellitus Usually associated with individuals under age 30 A Underweight A Overweight B May be controlled with oral agents B Incidence of complications C Gradual onset B Question 7 1 / 1 pts Exercise 1 - Question 7 A patient recently diagnosed with diabetes mellitus asks the nurse about potential causes. The nurse correctly recognizes that which factors may be considered to have a causative relationship with the disease? Select all that apply. Obesity Autoimmune disorder development Ethnicity Lifestyle Caucasian Genetic factors Question 8 1 / 1 pts Exercise 1 - Question 8 Match each diagnostic test for diabetes with its corresponding function. (Hint: See Box 11-2 in your textbook.) (A) Test used to determine the presence of either type 1 or type 2 diabetes. (B) The administration of a carbohydrate solution followed by drawing a blood specimen to assess the level of blood glucose hours later. (C) Drawing of a blood sample after a period of fasting, typically 8 hours. (D) Used to measure the level of glucose that has been incorporated into the body's hemoglobin. Fasting blood glucose C Postprandial blood glucose B Glycosylated hemoglobin D C peptide A Question 9 1 / 1 pts Exercise 1 - Question 9 Match each type of insulin with its correct onset of action after administration. (A) 15-30 minutes (B) 30-60 minutes (C) 1-2 hours (D) 1-3 hours (E) 2-4 hours Humalog A Regular B NPH E Lente (70/30) D Lantus C Question 10 0 / 1 pts Exercise 1 - Question 10 Most available insulin is U/[1]. 100U s 100 Question 11 1 / 1 pts Exercise 1 - Question 11A Indicate whether the following statement is true or false. Urine testing is the recommended way of monitoring glucose levels in the IDDM patient. True False Question 12 1 / 1 pts Exercise 1 - Question 11B Indicate whether the following statement is true or false. Lantus should never be mixed with regular insulin. True False Question 13 0 / 1 pts Exercise 1 - Question 11C Indicate whether the following statement is true or false. Patients with diabetes can choose between insulin or oral agents. True False Question 14 0 / 1 pts Exercise 1 - Question 12 Insulin should be administered to the [1] tissue. Subcu s subcutaneous Question 15 1 / 1 pts Exercise 1 - Question 13 Which is the site with the fastest rate of insulin absorption? Abdomen Arms Thighs Buttocks Question 16 0 / 1 pts Exercise 1 - Question 14 The loss of fat deposits as a result of insulin administration is known as Fatty acid . 1: Fatty insulin 2: acid lipodystrophy Question 17 0 / 1 pts Exercise 1 - Question 15 The only insulin that can be administered intravenously is [1]. human regular insulin s regular insulin Question 18 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Harry George (Room 401). Click Get Report and read the Clinical Report. Click Go to Nurses' Station and then click Chart. Click 401 to view Harry George's chart. Click the Emergency Department tab and review the information given. Click the Laboratory Reports tab and review the information given. Exercise 2 - Question 1 What was Harry George's plasma blood glucose upon his arrival at the emergency department? 380 380 mg/dL Question 19 1 / 1 pts Exercise 2 - Question 2 Harry George's HbA1C is [1]. 1.9 s 1.9 Question 20 0 / 1 pts Exercise 2 - Question 3 Based on the HbA1C level, what inferences can be made about Harry George's typical blood glucose levels? Harry George's blood glucose levels are most often between 130 and 150 mg/dL. Harry George's blood glucose levels are most often between 150 and 175 mg/dL Harry George's blood glucose levels are most often between 175 and 200 mg/dL. Harry George's blood glucose levels most often exceed 200 mg/dL. Question 21 Not yet graded / 1 pts Exercise 2 - Question 4 What is the desired blood glucose level for a patient with diabetes? lower the blood glucose level below 126mg/dl Clic The goal of treatment and management of diabetes is to maintain a blood glucose level at or below 126 mg/dL. Question 22 1 / 1 pts Exercise 2 - Question 5 Which type of diabetes does Harry George have? Diabetes insipidus Type 1 diabetes mellitus Type 2 diabetes mellitus Prediabetes Question 23 Not yet graded / 1 pts Exercise 2 - Question 6 What medication does Harry George take at home to control his diabetes? glyburide 1.25mg Glyburide 1.25 mg daily Question 24 1 / 1 pts Exercise 2 - Question 7 Which action best describes the mechanics of the drug you identified in the previous question? Stimulates the beta cells of the pancreas to release insulin Works to reduce hepatic glucose production Works to increase cell receptiveness to the body's natural insulin Inhibits glucose conversion to glucagon Question 25 Not yet graded / 1 pts Exercise 2 - Question 8 In addition to his daily scheduled medications to control his diabetes, Harry George has a sliding scale. Describe the use of a sliding scale. A sliding scale is used to provide variable coverage for the differing levels of blood glucose a patient may have. Question 26 0.5 / 1 pts Exercise 2 - Question 9 When caring for Harry George, the nurse notes that his blood glucose level is less than 150 mg/dL. What actions by the nurse are most appropriate? Select all that apply. Hold the prescribed dose of oral hypoglycemic medication. Provide him with a carbohydrate snack. Notify the health care provider. Document the findings. Administer the prescribed oral hypoglycemic medication. Question 27 1 / 1 pts Exercise 2 - Question 10 During an illness what is the recommended frequency of blood glucose monitoring for the patient? Hourly Every 1 to 2 hours Every 4 hours Every 8 hours Question 28 Not yet graded / 1 pts Exercise 2 - Question 11 What impact might illness have on Harry George's blood glucose? blood glucose levels can be affected by the stress created during illness and surgery. Blood glucose levels can be affected by the stress created during illness and surgery. These stressors can increase blood glucose levels. Question 29 Not yet graded / 1 pts Exercise 2 - Question 12 How does Harry George's diabetes affect his health status? For which additional complications might he be at risk because of his diabetes? kidney damage A diagnosis of diabetes affects all aspects of a patient's health. Patients with diabetes are at an increased risk for the development of infection, peripheral vascular complications, and visual disturbances. Question 30 Not yet graded / 1 pts Click Return to Nurses' Station. Click 401 at the bottom of the screen to enter Harry George's room. Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 0735: Symptom Management. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 13 What nonverbal behaviors are displayed by the patient, indicating a problem that needs to be addressed? anxiety, trembling Harry George appears nervous and jittery. His hands are trembling. Question 31 Not yet graded / 1 pts Exercise 2 - Question 14 During the talk between Harry George and his sitter, what needs and concerns are voiced? he is alcohol Harry George reports being in pain and says that he needs a cigarette and his "bottle." Question 32 Not yet graded / 1 pts Click Chart and then 401 to view Harry George's chart. Click the Physician's Orders tab and review the orders. Exercise 2 - Question 15 What is the frequency of Harry George's blood glucose assessments? 4x The blood glucose monitoring is ordered four times per day—before meals and at bedtime. Question 33 Not yet graded / 1 pts Exercise 2 - Question 16 What type of dietary management is being implemented? 1800 cals daily 1800 calories per day Question 34 1 / 1 pts Exercise 2 - Question 17 Which statement concerning Harry George's prescribed diet is correct? The diet will consist of three full meals per day to prevent snacking. The fat content should consist of no more than 30% of the caloric intake. 60% to 70% of the calories in the diet should be from carbohydrates to ensure energy. Snacks should be avoided to reduce blood glucose fluctuations. Question 35 Not yet graded / 1 pts Exercise 2 - Question 18 Harry George should be assessed for teaching needed in which areas? diet, exercise, nutition His diagnosis Dietary restrictions Medications Question 36 Not yet graded / 1 pts Click Return to Room 401. Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 0755: Disease Management. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 19 While talking with his sitter, Harry George continues to voice the need for his own "medication." What technique does the sitter attempt to employ to manage this request? The sitter attempts to use distraction, by offering to play cards, in order to get Harry George's mind off of his need for alcohol. This is also an attempt to pass time until the pain medication begins to take effect. Lesson 04 - Electrolyte Imbalances, Part 1 Exercise 1 - Question 1 Describe the general function of electrolytes. Electrolyes are composed of minerals such as sodium potasssium and chloride, Helps maintain normal fluid levels, they play a role in conducting nervous impulses, contracting muscles, and keeping body hydrated and regulating PH levels Electrolytes are substances dissolved in body fluids that carry an electrical charge. The difference in the electrolyte concentration between the intracellular fluid (ICF) and the extracellular fluid (ECF) helps to maintain membrane excitability and allows for transmission of nerve impulses. Question 2 1 / 1 pts Exercise 1 - Question 2 Match each term with its corresponding definition. (A) A negatively charged ion (B) A substance in body fluids that carries an electrical charge; an electrolyte (C) A positively charged ion Anion A Cation C Ion B Question 3 1 / 1 pts Exercise 1 - Question 3 Match each condition with its potential corresponding potassium alteration listed below. (Hint: See Table 11-1 in your textbook.) (A) Hypokalemia (B) Hyperkalemia Fluid overload A Alkalosis A Dehydration B Hyperaldosteronism A Kidney disease B Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 Identify the specific functions of potassium within the body. (Hint: See Chapter 11 in your textbook.) reduce water retention protect agianst stroke help prevent osteoporosis and kidney stones helps reduce blood pressure Regulation of intracellular osmolarity and volume Maintenance of electrical membrane excitability Regulate protein synthesis and glucose use and storage Question 5 Not yet graded / 1 pts Exercise 1 - Question 5 Describe the physiologic influences on potassium balance. The body maintains the right level of potassium by matching the amount consumed with the amount lost. Potassium is consummed in food and drinks that contain electrolytes and lost primarily in urine. Potassium is also lost in the digestive track if you sweat. Potassium is the major cation of the intracellular fluid (ICF). The normal serum potassium level ranges from 3.5 to 5.0 mEq/L or mmol/L. The normal ICF potassium level is about 140 mEq/L (mmol/L). The main controller of the ECF potassium is the sodium-potassium pump within the membranes of all body cells. This pump moves extra sodium ions from the ICF and moves extra potassium ions from the ECF back into the cell. In this way, the serum potassium level remains low and the cellular potassium remains high. Question 6 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses’ Station. Click on Chart and then on 403. Click on Laboratory Reports. Exercise 2 - Question 1 What was Piya Jordan’s initial potassium level on Monday at 2200? 3.3 mEq/ dl 3.3 mEq/L Question 7 1 / 1 pts Exercise 2 - Question 2 When considering Piya Jordan's age, which is a therapeutic serum potassium level? 2.5 to 4.5 mEq/dL 3.5 to 5.0 mEq/L 4.0 to 6.0 mEq/L 4.0 to 6.5 mEq/L Question 8 Not yet graded / 1 pts Click on Emergency Department and review this record. Exercise 2 - Question 3 What would be the most likely cause for hypokalemia in this patient? (Hint: See Table 11-7 in your textbook.) Vomiting, nausea Prolonged nausea and vomiting Question 9 Not yet graded / 1 pts Click on Physician's Orders. Scroll down and review the orders for Monday at 2200. Exercise 2 - Question 4 What did the physician order to treat this electrolyte imbalance? Is this appropriate? Is the dilution and rate safe to administer? (Hint: See Chapter 11 in your textbook.) 20 MEQ potassium chloride in 250ml NS Iv infuse over two hours Normal Saline IV flush 10ml every 8 hours PRN to saline lock peripheral IV Ondansetron 4 mg IV every 6 hours PRN nausea Yes it is appropriate, and safe to administer The physician ordered potassium chloride 20 mEq in 250 mL NS to infuse over 2 hours. Yes, this is appropriate as an initial replacement because the patient’s potassium level was just under the normal limit of 3.5. However, if the patient has an ongoing potassium loss, additional supplementation may be necessary. The dilution of 20 mEq in 250 mL NS meets the pharmaceutical recommendation of no more than 1 mEq/10 mL of solution; the rate of 125 mL or 10 mEq KCl per hour also meets the maximum recommended infusion rate of 5 to 10 mEq/hr. Question 10 Not yet graded / 1 pts Click on Laboratory Reports. Exercise 2 - Question 5 What was Piya Jordan’s potassium level for Tuesday at 0630? Was the physician’s order for potassium replacement effective? Is there any other treatment ordered that would be a cause for concern? 3.8 Yes very effective the level increased from 3.3 - 3,8 3.8. This is within normal limits; therefore the potassium infusion was effective. However, the nurse should continue to be concerned because Piya Jordan has a nasogastric (NG) tube and will therefore be at risk for further potassium loss. Question 11 Not yet graded / 1 pts Exercise 2 - Question 6 When administering potassium chloride intravenously, what guidelines for the rate of administration should be observed? administration should be via a volumetric infusion pump and the rate should be no more than 20 mEqs a hour. Electrolytes should be be monotiored to dtermine the need for further infusions and to avoid hyperkalemia. The infusion should be checked regularly for redness and inflammation. The concentration of potassium for intravenous administration via a peripheral line should not exceed 40mm/L, as higher strength can cause phlebitis and pain. The rate of potassium should be no more than 20 mEq/hr. No more than 30 mEq/L should be administered. Question 12 Not yet graded / 1 pts Click on Return to Nurses' Station. Click on 403 at the bottom of your screen. Click on Patient Care and then on Physical Assessment. Complete physical assessment of Piya Jordan by clicking on the body categories (yellow buttons) and body subcategories (green buttons). Click on Take Vital Signs. Exercise 2 - Question 7 Specifically looking for clinical manifestations of hypokalemia, document your findings, focusing on the assessment areas listed below. Place an asterisk by any findings that correlate with hypokalemia. (Hint: Refer to Chapter 11 in your textbook.) Respiratory Musculoskeletal Cardiovascular Neurologic Intestinal Respiration: bilateral breath sounds clear and equal with decreased aeration in both lower lobes Musculoskeletal: Mild weakness in strength, Mild weakness slow and unsteady gait Cardiovascular:Apical rhythm irregular with atrial fibrillation noted on telemetry monitor Nuerologis- impaired sensation and movement intestinal: decrease in bowel sound Respiratory: Lungs clear to auscultation, diminished in bases bilaterally* No cough Respiratory rate 25, regular (Respiratory rate will vary depending on when vital signs are taken, but should be between 23 and 25.) Musculoskeletal: Moves all extremities equally with mild weakness* noted in both upper and lower extremities Slow and unsteady gait Hand grasps moderately strongly Reflexes intact Cardiovascular: Apical pulse irregular* Atrial fibrillation S1 and S2 normal; no clicks, rubs, or murmurs Peripheral pulses 2+ Neurologic: Oriented to person only* Speech slow and slurred* Mildly confused, restless, and agitated* Intestinal: Absent bowel sounds* Abdomen tender (postoperative incision) Question 13 Not yet graded / 1 pts Click on Chart and then on 403. Then click on Laboratory Reports. Exercise 2 - Question 8 What was the potassium level that was drawn on Wednesday at 0630? 3.4 3.4 Question 14 Not yet graded / 1 pts Exercise 2 - Question 9 Explain the etiology for this recurrence of hypokalemia. patient potassium levels keep fluctuating, despite the drugs prescribed Continuous NG tube suctioning Question 15 Not yet graded / 1 pts Click on Physician’s Orders. Exercise 2 - Question 10 What did the physician order in response to today’s potassium level? Potassium chloride 20 mEq IV in 250 ml NS over 2 hrs Potassium chloride 20 mEq IV in 250 mL NS to infuse over 2 hours Question 16 Not yet graded / 1 pts Prepare to administer this ordered dose of potassium chloride to Piya Jordan by completing the following steps: Click on Return to Room 403. Click Medication Room on the bottom of your screen. Click on IV Storage near the top of your screen. Click on the bin labeled Small Volume and review the list of available medications. (Note: You may click on Review MAR at any time to verify correct medication order. Remember to click on the correct tab and to look at the patient name on the MAR to make sure you have the correct patient's record. Click on Return to Medication Room after reviewing the correct MAR.) From the list of medications in the bin, select potassium chloride. Click Put Medication on Tray and then on Close Bin. Click View Medication Room. Click on Preparation. Select the correct medication to administer; then click Prepare. Wait for instructions or questions from the Preparation Wizard. Then click on Next. Choose the correct patient to administer this medication to. Click on Finish. You can click Review Your Medications and then on Return to Medication Room when ready. From the Medication Room, go directly to Piya Jordan’s room by clicking on 403 at the bottom of your screen. Before you administer IV medications, the patient’s IV site must be assessed. Click on Patient Care and then on Physical Assessment. Click on Upper Extremities. Click on Integumentary from the system subcategories. Exercise 2 - Question 11 Document the IV site assessment findings below. Is it appropriate to administer the IV potassium at this time? Skin warm, dry, and intact. No rashes or lesions. Pressure points free of redness or irritation. Nails smooth. Peripheral intravenous site clear without redness or edema. Yes, it is safe to administer the Potassium Chloride at this time. Peripheral IV site clear without redness or edema. Yes, it is appropriate to administer the IV potassium. Question 17 Not yet graded / 1 pts After you have collected the appropriate assessment data and are ready for administration, click on Medication Administration. (Note: If you are not still in the Patient Care screen, you will need to first click on Patient Care and then on Medication Administration.) On the left side of the window that appears, select the correct patient name and room number. If you prepared the patient's medication properly, the name of the medication will appear in the middle window. Complete the Administration Wizard and click Administer to Patient when done. Check Yes when asked whether this drug administration should be documented on the MAR and then click on Finish. Now click on MAR at the top of your screen. Exercise 2 - Question 12 What are Piya Jordan’s scheduled morning medications? What medication would you question giving her, and for what reason? (Hint: See Chapter 11 in your textbook.) Morphine Enoxaparin Digoxin Cefoferan I would question giving her morphine in the morning it is a narcotic and will sedate her heavily, giving alot to her will cause addiction and distress if it become dependent on it. Digoxin 0.5 mL daily Morphine sulfate PCA pump protocol The nurse would want to question the administration of digoxin until after the potassium has been infused. Hypokalemia increases the risk of digoxin toxicity. Piya Jordan’s digoxin level was elevated on admission (2.1) and is currently just below the upper therapeutic limit at 1.8. Therefore she would be at risk for digoxin toxicity if the full dose was administered while she was hypokalemic. It would be wise for the nurse to discuss this issue with the attending provider. Question 18 Not yet graded / 1 pts Exercise 2 - Question 13 Piya Jordan complains of pain at the IV site while the potassium is infusing. What interventions are appropriate at this time? Stop the infusion at the first sign of redness or pain apply warm moist compresses to the area document the patients reaction to the injection if indicated, insert a catheter at a different site preferably the opposite arm using a larger vein or smaller device and restart the infusion Stop the infusion immediately and assess the site for extravasation. Question 19 1 / 1 pts Exercise 2 - Question 14 When considering pain at the site of the IV infusion, which manifestations are consistent with extravasation? Select all that apply. Pain Warmth Cool skin at site Absence of blood return Swelling Red streaking of skin over vein Question 20 Not yet graded / 1 pts Now let's see how you did! Click on Leave the Floor at the bottom of your screen. From the Floor Menu, select Look at You Preceptor's Evaluation. Then click on Medication Scorecard. Exercise 2 - Question 15 Disregard the report for the routine scheduled medications, and instead note below whether or not you correctly administered the potassium chloride. If not, why do you think you were incorrect in administering this drug? According to Table C in this scorecard, what are the appropriate resources that should be used and important assessments that should be completed before administering this medication? Did you utilize and perform them correctly? No it was incorrect administration, the order was potassium chloride 20 mEq in 250 ml NS to infuse over 2 hrs. The potassium chloride should be administered via the intermittent IV route into a peripheral line. The other rights of medication administration that must be followed would be to identify the correct patient by looking at the ID band, assessing allergies, and identifying the correct drug, time, and route by checking the patient’s MAR. The patient’s lab results (potassium level) should be verified before administration. Question 21 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Patricia Newman (Room 406). Click on Go to Nurses’ Station. Click on Chart and then on 406. Click on Laboratory Reports. Exercise 3 - Question 1 What was Patricia Newman’s initial potassium level this morning? 3.3 3.2 mEq/L Question 22 Not yet graded / 1 pts Click on History and Physical. Exercise 3 - Question 2 What would be the most likely cause for hypokalemia in this patient? weakness, medications, mood changes, muscle aches Chlorothiazide 500 mg daily; diuretic therapy with insufficient increase in potassium intake Question 23 Not yet graded / 1 pts Click on Physician's Orders. Exercise 3 - Question 3 What did the physician order on Wednesday at 0730 to treat this electrolyte imbalance? Increase Potassium chloride to 40 mEq/liter in IV fluid. Increase potassium chloride to 40 mEq per liter Question 24 Not yet graded / 1 pts Exercise 3 - Question 4 What is missing from this order? The rate of the IV infusion Question 25 Not yet graded / 1 pts Exercise 3 - Question 5 Where could you verify this missing information? KARDEX Look at the physician’s initial and most recent IV rate orders. You can also call the physician if you cannot find the data for this specific order. Question 26 Not yet graded / 1 pts Exercise 3 - Question 6 What is the difference between the treatment of hypokalemia for Piya Jordan and that for Patricia Newman? Provide a rationale for the difference. Piya potassium is higher than Patricia. Although Piya Jordan’s potassium level was slightly higher than Patricia Newman’s, Piya Jordan received 20 mEq of KCl (potassium aliquots) over 2 hours because she is at high risk for hypokalemia related to NG-tube drainage. Patricia Newman’s electrolyte loss is slightly less acute; therefore an increase of potassium chloride by 20 mEq over a 13-hour period would be sufficient. Question 27 Not yet graded / 1 pts Exercise 3 - Question 7 Look again at the physician’s orders. Is there an order for any follow-up lab work? What is the nurse’s responsibility in regard to follow-up lab work, and how would you handle this situation? Send sputum for gram stain, culture ans sensitivity. CBC and ABG chest xray The nurse is responsible to schedule the labs for patricia, by scheduling the lab collection required specimen, then labeling the specimen, and providing the appropriate storage for the specimen until sent off to lab. No, there is no order for follow-up labs. Follow-up lab work is part of the evaluation of the interventions. The nurse should contact the physician with respect and professionalism to obtain an order for follow-up serum electrolyte levels. Question 28 1 / 1 pts Exercise 3 - Question 8 When planning Patricia Newman's dietary intake, which selection is considered the best source of potassium? Salmon Eggs Bread Oatmeal Question 29 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on 406 at the bottom of the screen. Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 0740: Evaluation—Response to Care. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2- minute intervals if the video is not yet available. Then click again on Patient Care and then on NurseClient Interactions to refresh the screen.) Exercise 3 - Question 9 Although Patricia Newman is happy that her chest does not hurt like it did, what does she verbalize as a concern? Patricia newman is happy that her chest does not hurt like it did, what does she verbalize as a concern. “My breathing problems just seem to be getting worse and worse.” Question 30 Not yet graded / 1 pts Exercise 3 - Question 10 How does the nurse respond to this expressed concern? Is it an adequate response? The nurse expressed concerns about her potassium level and informed her that the potassium IV will be increased. No the response was not adequate. The nurse really does not respond to the patient’s concern regarding worsening lung disease. Instead, the nurse tells the patient that potassium was ordered and will be added to her IV while it is running. Although the patient does need teaching regarding her potassium, the nurse’s response did not use therapeutic communication techniques and the patient's needs were not met. Question 31 Not yet graded / 1 pts Exercise 3 - Question 11 For what clinical manifestations of hyperkalemia would you monitor Patricia Newman during her IV potassium therapy? (Hint: Consult the Drug Guide provided by clicking on the Drug icon in the lower left corner of your screen.) Cardiac arrhythmias,muscle weakness Paresthesias of extremities, heaviness of legs, cold skin, grayish pallor, hypotension, mental confusion, irritability, flaccid paralysis, cardiac dysrhythmias Lesson 05 - Electrolyte Imbalances, Part 2 Due No due date Points 40 Questions 40 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 8,280 minutes 2 out of 40 ** Some questions not yet graded Score for this quiz: 2 out of 40 * Submitted Aug 13 at 7:09am This attempt took 8,280 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 20 minutes to complete. Exercise 1 - Question 1 Complete the following information for calcium. Normal level Functions Major location Mechanism(s) of electrolyte hemeostasis Normal Level: Somewhere between 8.6 to 10.3 mg/dL Functions: It helps form and maintain healthy teeth and bones. A proper level of calcium in the body over a lifetime can help prevent osteoporosis. Major location: The teeth and the bones contain the most calcium. Nerve cells ,body tissues, blood, and other body fluids contain the rest of the calcium. Mechanism of electrolyte hemeostatis: Calcitritol regulates the levels of calcium and phosphorus in the blood and help maintains a healthy skeletal system.Bone resorption by osteoclast releases calcium into the bloodstream, which helps regulate calcium homeostatis. Normal level: 9.0-10.5 mg/dL Functions: Bone strength and density, enzyme activation, skeletal and cardiac muscle contraction, nerve impulse transmission, blood clotting Major location (e.g., ICF or ECF): ECF—in both bound and unbound form; majority is bound to albumin and not active; unbound or free calcium is ionized; free calcium is the active form Mechanism(s) to maintain electrolyte homeostasis: Absorbed in intestine Excreted in urine Levels regulated by parathyroid hormone (PTH) and thyrocalcitonin (TCT) PTH increases serum calcium TCT decreases serum calcium Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 Complete the following information for phosphorous. Normal level Functions Major location Mechanism(s) of electrolyte hemeostasis Phosphorous: 2.5 to 4.5 mg/dL Function: Is in the formation of bones and teeth. It plays an important role in how the body uses carbohydrates and fats.It is also needed for the body to make protein for the growth, maintenance, and repair of cells and tissues. Major location: is present in every cell of the body. Mosyly found in the bones and teeth Mechanisms: Maintianingphysological phosphate balancebalance is of Normal level: 3.0-4.5 mg/dL Functions: Needed for activating vitamins Needed in formation of adenosine triphosphate (ATP) Assists in cell growth and metabolism Major location (e.g., ICF or ECF): Major anion in the ICF; most found in bones Mechanism(s) to maintain electrolyte homeostasis: Increase in PTH decreases serum phosphorus Reciprocal relationship with calcium—when calcium increases, phosphorus decreases and vice versa Question 3 Not yet graded / 1 pts Exercise 1 - Question 3 Complete the following information for sodium. Normal level Functions Major location Mechanism(s) of electrolyte hemeostasis Normal level: 136-145 mEq/L Functions: Maintenance of ECF osmolarity Muscle contraction Cardiac conduction Nerve impulse transmission Maintenance of acid-base balance Maintenance of electroneutrality Major location (e.g., ICF or ECF): Major ECF cation Mechanism(s) of electrolyte homeostasis: Serum sodium balance is regulated by kidneys under the influence of aldosterone, antidiuretic hormone (ADH), and atrial natriuretic peptide (ANP); the sodium-potassium pump works to maintain lower ICF and higher ECF sodium levels. Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 Complete the following information for chloride. Normal level Functions Major location Mechanism(s) of electrolyte hemeostasis Normal level: 136-145 mEq/L FUnctions: Mainteance of ECF osolarity muscle contraction ,cardiac conduction Major location:Major ECF cation Mechanisms of electrolyte homeostatis:serum sodium Normal level: 98-106 mEq/L Functions: Maintenance of plasma acid-base balance Maintenance of plasma electroneutrality Formation of hydrochloric acid Major location (e.g., ICF or ECF): Major ECF anion Mechanism(s) on electrolyte homeostasis: Usually repelled by negative charges inside cell, but extracellular chloride can enter the cell when exchanged for another anion that is leaving the cell (chloride shift). Bicarbonate most common anion exchanged for chloride. Question 5 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Pablo Rodriguez (Room 405). Click on Go to Nurses' Station. Click on Chart and then on 405. Click on Laboratory Reports. Exercise 2 - Question 1 Record Pablo Rodriguez’s serum chemistry results for Tuesday 2000 and Wednesday 0730, focusing on the areas listed below. Identify any abnormal values by marking as H (for high) or L (for low). Sodium Potassium Chloride Calcium Phosphorus Magnesium Sodium: Tuesday:133L, wednesday 0730:134L Potassium: Tuesday 2000:3.8, wednesday 0730:3.6 Chloride: Tuesday2000:94 LWednesday:0730:102 Calcium:tuesday 2000:10.5, wednesday 0730:9.5 Phosphorus:Tuesday2000 2.2 L Magn:wednesday 0730- 1.9 Sodium Tuesday 2000: 133 (L) Wednesday 0730: 134 (L) Potassium Tuesday 2000: 3.8 Wednesday 0730: 3.6 Chloride Tuesday 2000: 94 (L) Wednesday 0730: 102 Calcium Tuesday 2000: 10.5 Wednesday 0730: 9.5 Phosphorus Tuesday 2000: 2.2 (L) Wednesday 0730: 2.3 (L) Magnesium Wednesday 0730: 1.9 Question 6 Not yet graded / 1 pts Click on History and Physical and review this record. Exercise 2 - Question 2 What would be the most likely cause for the hyponatremia noted in this patient on admission? Nausea and vomiting /3 days Nausea and vomiting for 3 days Question 7 Not yet graded / 1 pts Click on Physician's Orders. Exercise 2 - Question 3 What did the physician order to treat this electrolyte imbalance? Lactated ringers followed by IV Lactated Ringer's 1 L bolus followed by IV of D5 0.45% NS at 150 mL/hr Question 8 Not yet graded / 1 pts Exercise 2 - Question 4 Find Pablo Rodriguez’s sodium and chloride levels for Wednesday at 0730. Was the physician’s ordered treatment effective? Are there any changes in physician orders you might anticipate or suggest? Volime status was already low like his going into some kind of shock. Yes and no. The chloride level is within normal limits, but the sodium level is still slightly low. A suggestion might be to change the IV solution to NS rather than D5 0.45% in order to replace more sodium. Question 9 Not yet graded / 1 pts Exercise 2 - Question 5 Hyponatremia can be associated with both hypovolemia (actual sodium loss) and hypervolemia (dilutional). Initially, in the Emergency Department, what do you think Pablo Rodriguez’s volume status was? Explain. Hypovolemic secondary to persistent nausea and vomiting. The patient is normotensive but tachycardic —a compensatory mechanism for hypovolemia. Additionally, the Emergency Department physician notes dehydration as an admitting diagnosis. Question 10 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on EPR. Click on Login. Select 405 from the Patient drop-down menu and Intake and Output from the Category drop-down menu. Exercise 2 - Question 6 Record the intake and output shift totals for Tuesday 2300 and Wednesday 0700 for Pablo Rodriguez. Input: Tuesday: 150 Wednesday: 0700: 1283 Ouput: Tuesday:100 Wednesday:0700 Intake Tuesday 2300: 150 Wednesday 0700: 1283 Output Tuesday 2300: 100 Wednesday 0700: 925 Question 11 Not yet graded / 1 pts Exercise 2 - Question 7 Based on the above intake and output totals obtained after Pablo Rodriguez received IV replacement therapy, what factor(s) do you think may be contributing to the persistent hyponatremia? Explain your . intake is excedding the outake Although it is difficult to accurately assess the patient’s fluid status based on intake and output alone, the patient is excreting at least 75% of fluid administered; therefore the patient does not appear to be dehydrated at this point. There is a small potential for fluid overload and therefore dilutional hyponatremia related to the intake exceeding the output by approximately 1400 mL over a 32-hour time frame. However, these statements are purely assumptions because it is difficult to determine a patient’s fluid status based on intake and output alone. Question 12 Not yet graded / 1 pts Exercise 2 - Question 8 What other laboratory tests might be useful to more accurately determine the patient’s hydration status? (Hint: See Chapter 11 in your textbook.) BUN. Hgb, Hct, Blood urea nitrogen (BUN), hemoglobin (Hgb), hematocrit (Hct), serum osmolality, protein, glucose, and other electrolytes Question 13 Not yet graded / 1 pts Click on Return to Nurses' Station. Click on 405 at the bottom of your screen. Click on Patient Care and then on Physical Assessment. Complete a physical assessment of Pablo Rodriguez by clicking on the body system categories (yellow buttons) and subcategories (green buttons). Exercise 2 - Question 9 Specifically looking for clinical manifestations of hyponatremia, document your findings below. Cardiovascular Respiratory Neuromuscular Gastrointestinal Cardiovascular: apical pulse regular. Tachycardia with restlessness. S1 and S2 normal: no clicks,rubs, or murmurs Respiratory:lungs clear to ausculation Neuromuscular:alert and oriented *3 Gastrointestinal: Hypoactive bowel sounds Cardiovascular: Apical pulse regular. Tachycardia with restlessness. S1 and S2 normal; no clicks, rubs, or murmurs. No jugular vein distention (JVD). Peripheral pulses 2+ upper extremity, 1+ lower extremity. Respiratory: Lungs clear to auscultation, diminished left upper lobe. Labored and shallow respirations. Tachypnea. Nonproductive cough. Neuromuscular: Alert and oriented x 3. Speech age appropriate. Moderate anxiety and mild agitation. Generalized muscle weakness. Reflexes intact. Gastrointestinal: Hypoactive bowel sounds. No tenderness or masses. Question 14 Not yet graded / 1 pts Click on Chart and then 405. Click on Nursing Admission. Exercise 2 - Question 10 What other factors could be causing or contributing to the manifestations documented in question 9? Tachycardia and tachypnea weakness shallow respirations Tachycardia and tachypnea—anxiety, lung cancer Generalized weakness—secondary to malignancy and associated treatments Shallow respirations—anxiety, lung cancer Question 15 Not yet graded / 1 pts Exercise 2 - Question 11 Based on your s to questions 9 and 10, what conclusion can you make regarding these clinical manifestations and Pablo Rodriguez’s sodium levels? Although Pablo Rodriguez’s sodium level is low, it is not extremely deficient. At this level, patients may not always exhibit clinical manifestations. These symptoms are most likely related to the patient’s general poor health but could be exacerbated by the hyponatremia. You might expect these symptoms to improve slightly with correction of sodium levels but not necessarily return to normal. Question 16 Not yet graded / 1 pts Exercise 2 - Question 12 What other clinical manifestations of hyponatremia might you expect to find in other patients with this electrolyte imbalance? (Hint: See Chapter 11 in your textbook.) confused nausea diarrhea confusion diminished deep tendon reflexes behavioral changes increased intestinal motility nausea hyperactive bowel sounds diarrhea abdominal cramping hypotension decreased peripheral pulses light-headedness dizziness Question 17 Not yet graded / 1 pts Exercise 2 - Question 13 If Pablo Rodriguez’s sodium level were 120 (severe hyponatremia), how would the treatment vary? The patient would recieve small volume infusions of hypertonic The patient would receive small-volume infusions of hypertonic (2%-3%) saline via an IV controller with frequent monitoring. Question 18 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 60 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 3. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Pablo Rodriguez (Room 405). Click on Go to Nurses' Station. Click on Chart and then on 405. Click on Laboratory Reports. Exercise 3 - Question 1 What was Pablo Rodriguez’s calcium level on admission to the Emergency Department on Tuesday evening? 10.5 mg/dl 10.5 mg/dL Question 19 Not yet graded / 1 pts Exercise 3 - Question 2 How would you best describe this calcium level? High Pablo Rodriguez's calcium levels are at the highest end of the scale for normal. Question 20 Not yet graded / 1 pts Exercise 3 - Question 3 What was his phosphorus level during the same time frame? 2.2 mg/Dl 2.2 mg/dL Question 21 Not yet graded / 1 pts Exercise 3 - Question 4 How does this relate to his calcium level? Explain the pathophysiologic rationale supporting your . There is a reciprocal relationship between calcium and phosphorus. As the serum calcium levels increase, the serum phosphorus levels will decrease and vice versa. Therefore the decreased phosphorus level is directly related to Pablo Rodriguez’s high-normal calcium level. Question 22 Not yet graded / 1 pts Click on History and Physical. Exercise 3 - Question 5 What would be the most likely cause for Pablo Rodriguez’s calcium level? Malignancy:most likely direct invasion Malignancy; most likely direct invasion caused by metastatic non-small cell lung carcinoma Question 23 1 / 1 pts Exercise 3 - Question 6 Match each type of serum calcium imbalance with its potential cause listed below. (Note: Each imbalance may be used more than once.) (A) Hypercalcemia (B) Hypocalcemia Vitamin D deficiency B Hyperthyroidism A Hyperparathyroidism A Excessive intake of phosphorous containing foods B Kidney disease B Question 24 Not yet graded / 1 pts Click on Physician's Orders. Exercise 3 - Question 7 What medication did the emergency department physician order in response to Pablo Rodriguez's serum calcium levels? Pamidrone 90mg Iv over 2 hrs Pamidronate 90 mg IV over 2 hours Question 25 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on Drug Guide on the counter. Exercise 3 - Question 8 Describe the mechanism of action of the medication you identified in question 7. This is a bisphosphonate drug that prevents calcium from leaving the bones (inhibits resorption) and entering the blood. Question 26 Not yet graded / 1 pts Exercise 3 - Question 9 What nursing assessments are appropriate related to the administration of this medication? Assessing sounds monitoring the patients hgb assess vitals frequently Obtain and assess baseline electrolyte levels Monitor the patient’s Hgb and Hct, magnesium, and serum creatinine levels Provide adequate hydration, taking care not to overhydrate Assess vital signs frequently Be alert for potential gastrointestinal (GI) hemorrhage related to dose of 90 mg or greater Assess lung sounds Maintain the rights of medication administration Question 27 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on Chart and then on 405. Click on Laboratory Reports. Exercise 3 - Question 10 What were Pablo Rodriguez’s calcium and phosphorus levels this morning (Wednesday at 0730)? Calcioum 9.5 Phosphorus:2.3 Calcium 9.5 Phosphorus 2.3 Question 28 Not yet graded / 1 pts Exercise 3 - Question 11 Was the prescribed medication effective? Is the patient out of danger? Yes Yes, the serum calcium is lower and Pablo Rodriguez is not in any immediate danger. However, the patient is at risk for hypercalcemia secondary to ongoing malignancy issues and must be monitored closely. Question 29 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on Kardex and then on 405. Exercise 3 - Question 12 What IV fluids is Pablo Rodriguez receiving? D50.45 NS at 150ml hr D5 0.45% NS at 150 mL/hr Question 30 Not yet graded / 1 pts Exercise 3 - Question 13 What is the purpose of IV hydration in relation to serum calcium levels? IV hydration increases urine output and thus urine excretes calcium IV hydration increases urine output and thus urine excretion of calcium. Question 31 Not yet graded / 1 pts Exercise 3 - Question 14 Is this the normal solution you would expect to administer to a patient with hypercalcemia? If not, what solution would you expect and why? yes normal solution No, it is not the usual IV solution used for hydration to treat hypercalcemia. Typically, normal saline is ordered because sodium further increases the rate of calcium excretion in the urine. Question 32 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on MAR and then on 405. Exercise 3 - Question 15 What medication is scheduled to be administered at 1500? Nueutra Phos 1 cap Neutra-Phos 1 capsule Question 33 Not yet graded / 1 pts Exercise 3 - Question 16 What electrolyte imbalance will this medication correct? Explain your . It will directly increase the phosphorus levels and indirectly decrease calcium levels related to the reciprocal relationship between calcium and phosphorus. As you increase phosphorus levels, calcium levels will decrease, and vice versa. Question 34 Not yet graded / 1 pts Exercise 3 - Question 17 What nursing assessments must be completed before this drug is administered? GI assessment—signs and symptoms of gastric pain, nausea/vomiting, diarrhea Assess bowel sounds because Neutra-Phos can act as a laxative Assess calcium and phosphorus levels Question 35 Not yet graded / 1 pts Exercise 3 - Question 18 Do you have any concerns about administering this drug at this specific time? (Hint: Check the patient’s gastrointestinal [GI] history on admission.) Yes, the medication should be given with food to decrease stomach upset. Although the nurse could give the patient food at 1500, based on the patient’s history of nausea/vomiting, this medication should be given with meals. Question 36 Not yet graded / 1 pts Click on Return to Nurses’ Station. Go to Pablo Rodriguez's room by clicking on 405. Click on Patient Care and then on Physical Assessment. Complete a physical assessment on Pablo Rodriguez by clicking on the body system categories (yellow buttons) and subcategories (green buttons). Click on Take Vital Signs. Exercise 3 - Question 19 Document the findings of your assessment, focusing on the areas listed below. Cardiovascular Respiratory Neuromuscular Gastrointestinal Cardiovascular: Apical rate regular. No clicks, murmurs, or rubs. S1 and S2 normal. No juvenile vein distention. Lower extremity pulses +1 bilaterally. Capillary refill sluggish, more than 4 sec. Pulse and blood pressure within normal limits; values will vary depending on when vitals are taken. Respiratory: Lungs clear to auscultation, nonproductive cough. Decreased breath sounds in left upper lobe. Shallow respirations. Neuromuscular: Alert and oriented x 3. Mild anxiety. Reflexes intact. Generalized muscle weakness. Gastrointestinal: Bowel sounds auscultated in all four quadrants. Abdomen soft and nontender. Question 37 Not yet graded / 1 pts Exercise 3 - Question 20 Is Pablo Rodriguez demonstrating any clinical manifestations of hypercalcemia? If yes, describe the pathophysiologic basis for the symptoms. If not, explain why not. yes No clinical manifestations are noted because the patient’s calcium levels are within normal limits. Question 38 1 / 1 pts Exercise 3 - Question 21 If Pablo Rodriguez’s calcium level were 12.5, what other clinical manifestations might the nurse expect to find? Select all that apply. Cardiac dysrhythmias Tachycardia Bradycardia Cyanosis Flushed skin Pallor Confusion Profound muscle weakness Hyperreflexia Decreased GI motility Diarrhea Question 39 Not yet graded / 1 pts Exercise 3 - Question 22 Based on your vascular assessment of Pablo Rodriguez, what complication of hypercalcemia must the nurse vigilantly assess for? Explain. Deep vein thrombosis (DVT); hypercalcemia allows blood clots to form more easily whenever blood flow is poor. The assessment demonstrates decreased pulses and capillary refill in the lower extremity, making Pablo Rodriguez extremely at risk for DVT. Question 40 Not yet graded / 1 pts Exercise 3 - Question 23 After successful treatment of Pablo Rodriguez, the nurse must be alert for overcorrection of the electrolyte imbalance. For what clinical manifestations should the nurse monitor this patient related to hypocalcemia and hyperphosphatemia? Weak hypotension' tingling weak, thready pulse hypotension paresthesias tingling numbness irritable skeletal muscles (positive Chovstek’s, positive Trousseau’s signs) increased GI motility hyperactive bowel sounds abdominal cramping diarrhea Lesson 05 - Postoperative Complications Due No due date Points 29 Questions 29 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 190 minutes 2.2 out of 29 ** Some questions not yet graded Score for this quiz: 2.2 out of 29 * Submitted Aug 14 at 10:21am This attempt took 190 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 15 minutes to complete. Exercise 1 - Question 1 List several potential postoperative complications. Shock Hemmorrhage wound infection pulmonary embolism lung complications reaction to anesthesia Infection Wound dehiscence Respiratory complications Embolism Question 2 0 / 1 pts Exercise 1 - Question 2 The collapse of lung tissue, which results in the lack of adequate exchange of oxygen and carbon dioxide, is known as [1]. Emphysema s atelectasis Question 3 Not yet graded / 1 pts Hint: Refer to pages 416-418 in your textbook for the next several questions. Exercise 1 - Question 3 What is a pulmonary embolism? Is caused by the passage of a foreign substance(blood clot, fat,air, tumor disease or amniotic fluid) into the pulmonary artery or its branches with resulting obstruction of the blood supply to lung tissue and subsequent collapse. A pulmonary embolism is the passage of a foreign substance (blood clot, fat, air, tumor tissue, or amniotic fluid) into the pulmonary artery or its branches. This results in the obstruction of blood supply to lung tissue. Question 4 1 / 1 pts Exercise 1 - Question 4 When assessing the patient for a pulmonary embolism, which manifestation(s) can be anticipated? Select all that apply. Dull and achy pain Pain often described as sharp Pain that radiates to the back and neck Nonradiating pain Dyspnea Reduced respiratory rate Increased respiratory rate Increased pain with inspiration Question 5 0 / 1 pts Exercise 1 - Question 5 During the initial period after the onset and subsequent diagnosis of a pulmonary embolism, which treatment(s) can be anticipated? Select all that apply. Oxygen Oral anticoagulants Intramuscular antibiotics Intravenous anticoagulants Hydration Question 6 Not yet graded / 1 pts Exercise 1 - Question 6 How is a pulmonary embolism managed? Anticoagulant therapy is the primary treatment option for most patients with acute PE. The utilization of factor Xa antagonists and direct thrombin inhibitors, collectively termed Novel Oral Anticoagulants are likely to increase as they become incorporated into societal guidelines as first line therapy. Warfarin subcutaneous low molecular weight heparin Intervenous Heparin Oxygen therapy Hydration Anticoagulant medications Question 7 Not yet graded / 1 pts Exercise 1 - Question 7 What is the prognosis for a patient who develops a pulmonary embolism? Early diagnosis and appropriate treatment reduce mortality to 2% to 8%. Untreated PE carries a 30% mortality rate. If the embolism is treated, the prognosis is positive. There is only a 5% mortality with treated cases of pulmonary embolism. Question 8 0 / 1 pts Exercise 1 - Question 8 Which diagnostic test is considered to be the gold standard for detecting a pulmonary embolism? Chest radiography Ventilation perfusion scan CT scan Pulmonary angiography Question 9 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 2. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click Get Report and read the Clinical Report. Exercise 2 - Question 1 Are there any abnormal observations in the report? Respiration is low No Question 10 Not yet graded / 1 pts Exercise 2 - Question 2 Review the vital signs recorded in the change-of-shift report. Are they normal? 0715 vital signs: T 98.4, BP 128/74, P 88, RR 16, SpO2 93% i Yes they are norm `al Vital signs were reportedly stable after the 0731-1115 shift. The report for the 1901-0730 shift lists the following vital signs, which are within normal limits as well: T 98.4 BP 128/74 P 88 RR 16 SpO2 93% on room air Question 11 Not yet graded / 1 pts Click Go to Nurses' Station. Click on 404 at the bottom of the screen to enter the patient's room. Read the Initial Observations. Click Clinical Alerts and read the information provided. Exercise 2 - Question 3 Which clinical findings indicate a problem? shortness of breath. onset chest pain Clarence Hughes is complaining of chest pain and difficulty breathing. He is anxious, diaphoretic, and tachypneic. Question 12 0 / 1 pts Click Take Vital Signs. Exercise 2 - Question 4 What are Clarence Hughes' current vital signs? BP: 124/87 T: 97.6 HR: 121 RR: 36 1: 124/87 ~134/89 2: 97.6 ~98.2 3: 121 ~110 4: 36 ~36 Question 13 Not yet graded / 1 pts Exercise 2 - Question 5 Are any of the above results abnormal? If so, which? His heart rate is high, and respiratory rate is high. The blood pressure is slightly elevated. The heart rate and respiratory rate are also elevated. The respiratory rate is extremely elevated. Question 14 Not yet graded / 1 pts Exercise 2 - Question 6 What is Clarence Hughes' current oxygen saturation? Is this a normal value? If not, how should it be managed? 89, yes with his oxygen theraphy he is taking His SpO2 is ~92%. (s will vary slightly, depending on the exact time on the virtual clock.) Oxygen saturation levels are best when closest to 100%. Monitoring should continue. Oxygen may be initiated. Question 15 Not yet graded / 1 pts Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 1115: Interventions—Airway. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 7 What behavioral cues being demonstrated by Clarence Hughes indicate a potential health concern? Qq` Question 16 0.2 / 1 pts Exercise 2 - Question 8 Several nursing interventions are indicated after the onset of Clarence Hughes’ breathing problems. Rank the interventions below by matching them in the order in which they need to be completed. (A) First (B) Second (C) Third (D) Fourth (E) Fifth Notify the physician. A C Maintain the airway. C A Complete a focused assessment. B Document care provided. E D Provide education to the family concerning what is taking place. D E Question 17 Not yet graded / 1 pts Click Physical Assessment and complete a head-to-toe assessment. Exercise 2 - Question 9 Are there any significant findings identified in the integumentary assessment? Skin warm and moist. Diaphoresis all over Intact skin integrity without rashes or lesions. Scalp smooth and supple. Left leg swollen though without redness. Left leg wrapped in gauze dressing and ace wrap for support. Left leg incision well approximated, mildly swollen at site, no redness or drainage. Feet with some scabs and callouses. Toenails thick and rigid. There is diaphoresis to the upper chest. Mr. Hughes' color is pale. Question 18 Not yet graded / 1 pts Exercise 2 - Question 10 Are there any significant findings identified in the respiratory assessment? Yes, his respirations are fast Respirations are labored. He is tachypneic. Question 19 0 / 1 pts Exercise 2 - Question 11 Clarence Hughes should be placed in [1] position to facilitate air exchange. orthopneic s high Fowler's Question 20 Not yet graded / 1 pts Click Chart and then 404 to view Clarence Hughes' chart. Click the Physician's Orders tab and review the orders listed for 1120 on Wednesday. Exercise 2 - Question 12 What tests and interventions has the physician ordered? STAT labs: D-dimer, PT/INR/PTT, CBC, and ABGs. STAT chest x-ray STAT spiral CT STAT ventilation-perfusion scan Start cardiac telemetry monitoring Arterial blood gases Chest x-ray Ventilation perfusion scan Venous Doppler study Vital signs every 30 minutes Removal of the CPM machine Question 21 0 / 1 pts Exercise 2 - Question 13 The degree of anxiety is often directly tied to the amount of [1] hunger being experienced by the patient. s air Question 22 Not yet graded / 1 pts Click Return to Room 404. Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 1135: Change in Patient Condition. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 14 Now that the initial crisis has passed, what are the nurse's priorities concerning the family members? that he is going to die The family will now need reassurance and education concerning the events and the upcoming plans for care. Question 23 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 15 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 3. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click Get Report and read the report. Click Go to Nurses' Station. Click 404 at the bottom of the screen to enter Clarence Hughes' room. Read the Initial Observations. Click and review the Clinical Alerts. Exercise 3 - Question 1 What changes are noted in the patient's demeanor and clinical manifestations? patient seems in pain and diminishing The patient appears calmer. His vital signs are closer to normal limits now. There is no longer the continued struggle to breathe. No evidence of chest pain. Question 24 Not yet graded / 1 pts Click Take Vital Signs and review the results. Exercise 3 - Question 2 What is the significance of the increasing SpO2 level? oxygen is a vital to maintain the health of all tissues in the body This increasing value demonstrates an improvement in the oxygenation of the patient, which is a positive sign. Question 25 Not yet graded / 1 pts Click Chart and then 404 to review Clarence Hughes' chart. Click the Physician's Orders tab and review the information given. Exercise 3 - Question 3 What medication has been ordered to manage Clarence Hughes' condition? Describe the administration of this medication. Oxycodone Enoxaparin 30 mg subQ every 12 hours to start this evening. Heparin has been ordered. An initial bolus dosage is to be given; then an adjustable scale dosage will be administered. Question 26 Not yet graded / 1 pts Exercise 3 - Question 4 What is the method of action and the purpose for the administration of this medication? to ease the pain in chest Although it does not affect existing clots, it does aid in prevention of new clot formation. Question 27 Not yet graded / 1 pts Exercise 3 - Question 5 What is the classification of this medication? N/A Anticoagulant Question 28 1 / 1 pts Exercise 3 - Question 6 During therapy with the medication identified in question 4, which laboratory test is most important to monitor? PTT Hgb Hct WBC ESR Question 29 0 / 1 pts Exercise 3 - Question 7 Once the intravenous anticoagulant therapy has been tapered off, Clarence Hughes can anticipate continuing on oral therapy for a period of: 3 months. 6 months. 9 months. 363 36 1 year. 18 months. Lesson 08 - Prioritizing Care for the Patient with a Pulmonary Disorder Due No due date Points 26 Questions 26 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 392 minutes 11.17 out of 26 ** Some questions not yet graded Score for this quiz: 11.17 out of 26 * Submitted Aug 14 at 3:43pm This attempt took 392 minutes. Question 1 1 / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 30 minutes to complete. Exercise 1 - Question 1 Which characteristics are associated with emphysema? Select all that apply. Emphysema affects both men and women. Emphysema symptoms typically begin to manifest while the patient is in the mid- to late 30s. The disorder is characterized by changes in the alveolar walls and capillaries. Disability often results in patients diagnosed with emphysema between ages 50 and 60 years. Heredity may play a role in the development of emphysema. Question 2 1 / 1 pts Exercise 1 - Question 2 When diagnostic tests are ordered to confirm the presence of emphysema, which tests may be anticipated? Select all that apply. Thoracentesis Arterial blood gases Complete blood cell count Chest x-ray Bronchoscopy Pulse oximetry Question 3 1 / 1 pts Exercise 1 - Question 3 When caring for a patient diagnosed with emphysema, the nurse should anticipate which result for a pulmonary function test? Reduced residual volume Reduced airway resistance Increased ventilatory response Increased residual volume Question 4 1 / 1 pts Exercise 1 - Question 4 The complete blood cell count will reflect which result(s) in a patient diagnosed with emphysema? Reduced erythrocyte count Elevated erythrocyte count Elevated erythrocyte count and reduced hemoglobin Reduced erythrocyte count and elevated hemoglobin Question 5 1 / 1 pts Exercise 1 - Question 5 In the patient who is experiencing emphysema, which result best reflects the anticipated results of pulmonary function tests? Increased PaO2 Decreased PaO2 Reduced residual volume Increased total lung capacity Question 6 Not yet graded / 1 pts Exercise 1 - Question 6 Describe the disease process associated with emphysema. the air sacs in the lungs alveoli are damaged. over time, the inner walls of the air sacs weaken and rupture creating larger air spaces instead of many small ones. Emphysema is associated with an enlargement of the alveoli. Inflammation of the bronchi, bronchioles, and alveoli occurs as a result of chronic irritation. The narrowed lumen causes the air to become trapped during expiration. This results in distention and rupture. As a result, the alveoli scar and lose their elasticity. Question 7 1 / 1 pts Exercise 1 - Question 7A Indicate whether each statement is true or false. An inherited form of emphysema is due to an oversecretion of a liver protein known as ATT. True False Question 8 1 / 1 pts Exercise 1 - Question 7B Indicate whether each statement is true or false. Hypercapnia does not develop until the later stages of emphysema. True False Question 9 Not yet graded / 1 pts Exercise 1 - Question 8 Discuss the use of exercise in the care and management of the patient diagnosed with emphysema. it improves aerobic capacity,endurance, and strength; improves and maintains functional performance in everyday life. Physicians often recommend the initiation of aerobic exercises, such as walking. This exercise improves the body's use of oxygen. Question 10 0 / 1 pts Exercise 1 - Question 9 [1] is an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart due to hypertension of the pulmonary circulation. pulmonary arterial hypertension s Cor pulmonale Question 11 Not yet graded / 1 pts Exercise 1 - Question 10 What are the management options for the patient with emphysema? theraphy, medications Home oxygen therapy Chest physiotherapy Bronchodilator medications Anticholinergic medications Pulmonary rehabilitation therapy Question 12 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 3. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Patricia Newman (Room 406). Click Get Report and read the Clinical Report. Click Go to Nurses' Station. Click 406 at the bottom of the screen. Read the Initial Observations. Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 1500: Discharge Planning. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 1 Discuss Patricia Newman's demeanor during the video interaction. very excited The patient appears optimistic. She has a friend present who is willing to help her. She seems interested in the upcoming discharge. Question 13 Not yet graded / 1 pts Exercise 2 - Question 2 What appear to be the patient's biggest concerns during this interaction? The patient seems somewhat hesitant about the oxygen delivery to her home. She is interested in smoking cessation programs. Question 14 Not yet graded / 1 pts Click Physical Assessment and complete a head-to-toe assessment. Exercise 2 - Question 3 What evidence suggests that Patricia Newman's condition is improving? productive cough,oxygen saturation increase, Her vital signs are improving. Her respiratory system assessment shows improved aeration and reduced wheezes. No rhonchi are noted in this assessment. Question 15 Not yet graded / 1 pts Exercise 2 - Question 4 Are there any assessment findings that could potentially have a negative implication for Patricia Newman's discharge to home? If so, explain. yes she is still having a hard time physically Yes. She still has weakness and some degree of activity intolerance. Question 16 0 / 1 pts Exercise 2 - Question 5 When preparing to discharge Patricia Newman, the nurse will need to review the patient's understanding of the correct use of the metered inhaler. Which observations would indicate the need for additional teaching? Patricia Newman rinses her mouth out with water immediately after inhalation. Patricia Newman waits 1 minute between inhaling her first and her second dose. Patricia Newman shakes the medicine container before use. Patricia Newman holds her breath as long as she can after administering the medication. Question 17 0.67 / 1 pts Exercise 2 - Question 6 As you develop Patricia Newman's plan of care, which are priorities at this time? Select all that apply. Dietary counseling Preparation for discharge Referrals for smoking cessation programs Requesting a consultation with physical therapy Requesting a consultation with social services Question 18 Not yet graded / 1 pts Exercise 2 - Question 7 Develop three nursing diagnoses for Patricia Newman. Note: Responses may vary. Activity intolerance related to respiratory infection Knowledge deficit related to home therapy Anxiety related to discharge planning Question 19 Not yet graded / 1 pts Click Chart and then 406 to view Patricia Newman's chart. Click the Nursing Admission tab and review the information given. Exercise 2 - Question 8 Identify Patricia Newman's social concerns. she dont have alot of money She reports that her limited financial resources interfere with her ability to follow prescribed treatment plans. Question 20 1 / 1 pts Exercise 2 - Question 9 Which statement accurately reflects an aspect of Patricia Newman's needs? She has numerous friends and family members available to provide assistance. She appears self-sufficient and needs little outside help. She is somewhat socially isolated. Her significant other will be available as needed for assistance after discharge. Question 21 Not yet graded / 1 pts Exercise 2 - Question 10 Discuss the implications of these social concerns on the nurse's plan of care for Patricia Newman. her social isolation reduces to help and social support. Her social isolation reduces her access to help and social support. If she is unable to afford to maintain the prescribed treatments, her risk for continued complications is increased. Question 22 1 / 1 pts Click the Patient Education tab and review the information given. Exercise 2 - Question 11 Which dietary recommendations should be included in Patrician Newman's patient teaching? Select all that apply. Avoid resting before eating. Recommended oral fluid intake should be 1 to 2 L/day. 5 to 6 meals per day are recommended. Meals should be high in calories. Meals should be low in fiber. Moderate protein is recommended. Question 23 0.5 / 1 pts Exercise 2 - Question 12 As Patricia Newman prepares to go home, which are educational goals for her discharge? Select all that apply. Correct use of MDI and peak flow meter Understanding the rationale for and the proper performance of pursed-lip breathing and effective cough technique The need to be sedentary to avoid further complications Understanding of and compliance with her prescribed medication therapy Compliance with progressive activity/exercise goals Question 24 Not yet graded / 1 pts Exercise 2 - Question 13 Considering Patricia Newman's social and financial history, which goals may be a challenge for her to meet? The financial constraints may hamper her ability to follow the dietary recommendations and to obtain the prescribed medications after discharge. Question 25 1 / 1 pts Exercise 2 - Question 14 When discussing immunization recommendations with Patricia Newman, what information should be included? The pneumonia vaccine is recommended every 2 years. The pneumonia vaccine cannot be taken during the same season as the influenza vaccine. The influenza vaccine is recommended each year. The influenza vaccine and the pneumonia vaccine are recommended each year. Question 26 Not yet graded / 1 pts Click the Physician's Orders tab. Exercise 2 - Question 15 What consultations have been ordered for Patricia Newman during this hospitalization? nutrient services occupational/physical theraphy Dietary services Occupational and physical therapy Social services Lesson 03 - Developing a Plan of Care for the Patient with Osteomyelitis Due No due date Points 23 Questions 23 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 32 minutes 2 out of 23 ** Some questions not yet graded Score for this quiz: 2 out of 23 * Submitted Aug 19 at 8:25pm This attempt took 32 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Virtual Hospital Activity This exercise will take approximately 60 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 2. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Harry George (Room 401). Click Get Report and read the Clinical Report. Click Go to Nurses' Station and then 401 to enter Harry George's room. Read the Initial Observations. Click Patient Care and complete a head-to-toe assessment Exercise 1 - Question 1 What are the two primary priorities for Harry George's care at this time? pain ans stress Management of pain and anxiety Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 What elements of the assessment or the Clinical Report did you use to make this decision? level of pain The patient reported his level of pain to be at 9 on a 10-point scale. The Clinical Report further supported the fact that the pain was interfering with his progress and abilities to participate in care. Anxiety was apparent in the description of his actions. Question 3 Not yet graded / 1 pts Exercise 1 - Question 3 How has pain interfered with Harry George's recovery? his pain has made him combative. As noted in the clinical report, Harry George refused to work with the physical therapist. Physical therapy is necessary to put him on the road to improvement of his condition. Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 Is Harry George's pain a new problem or one that has been ongoing? Give a rationale for your response. ongoing since motorcyle accident The pain was reported in the previous shift report; thus it is an ongoing problem. There are also reports that he has been combative at times. Question 5 Not yet graded / 1 pts Exercise 1 - Question 5 What nonpharmacologic interventions can be used to attempt to increase Harry George's level of comfort? pain managment and repostioning Repositioning with pillows Assessing the types of nonpharmacologic pain management he has successfully used in the past Distraction Music Question 6 Not yet graded / 1 pts Click Patient Care and then Nurse-Client Interactions. Select and view the video titled 1120: Wound Management. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 1 - Question 6 What behaviors demonstrated by Harry George further support his report of pain and his level of anxiety? he is very frustrated Harry George is restless and has tremors in his extremities. During the exchange with the nurse, his tone and specific words highlight his frustration. Question 7 Not yet graded / 1 pts Now select and view the video titled 1125: Injury Prevention. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and Nurse-Client Interactions to refresh the screen.) Exercise 1 - Question 7 During the interaction with his sitter, Harry George continues to appear nervous. His movements reflect jitteriness, and his extremities are trembling. To what can these behaviors be attributed? Alcohol withdrawal Question 8 Not yet graded / 1 pts Click MAR and then tab 401 to review Harry George's MAR. Exercise 1 - Question 8 The physician has prescribed chlordiazepoxide hydrochloride. Other than anxiety, what is an indication for the use of this medication? alcohol withdrawl Alcohol withdrawal Question 9 1 / 1 pts Exercise 1 - Question 9 Which nursing implications are indicated with the administration of chlordiazepoxide hydrochloride? Select all that apply. Assess vital signs before administration. Increase ambulation immediately after administration. Administer cautiously in patients with liver impairments. Institute safety precautions in regard to ambulation. This medication may be used in patients who have recently ingested alcohol. Question 10 Not yet graded / 1 pts Exercise 1 - Question 10 In addition to the chlordiazepoxide, what alternative(s) has the physician ordered to reduce Harry George's anxiety? lorazepam Lorazepam Question 11 Not yet graded / 1 pts Exercise 1 - Question 11 What factors will determine which of the medications should be given? The lorazepam is indicated for more intense anxiety. It has stronger sedating effects. The chlordiazepoxide's use is geared more directly to the management of alcohol withdrawal. Question 12 Not yet graded / 1 pts Exercise 1 - Question 12 What medication has been ordered to manage Harry George's pain? Hydromorphone hydrochloride Hydromorphone hydrochloride Question 13 Not yet graded / 1 pts Exercise 1 - Question 13 Does Harry George have any allergies that prevent him from being medicated with the drug prescribed? (Hint: Check his armband.) no.his only allergies are to an unidentified antinfective medication No. His only allergies are to an unidentified antiinfective medication. Question 14 1 / 1 pts Exercise 1 - Question 14 Harry George's last dose of medication for pain was given at [1]. 0715 s 0715 Question 15 Not yet graded / 1 pts Click Return to Room 401. Then click the Drug icon. Review the information provided for the medication you identified in question 12. Exercise 1 - Question 15 What elements of Harry George's medical/social history should be taken into consideration when administering this drug? His history of alcoholism His history of alcoholism Question 16 Not yet graded / 1 pts Exercise 1 - Question 16 Are there any special administration precautions that must be observed when giving this medication IV push? given slowly over 2-3 mins The medication must be given slowly, over a period of 2 to 3 minutes. When this drug is administered IV push, there is an increased risk for anaphylactic reaction. Therefore close attention must be paid to the patient's vital signs and his response after the drug is administered. Question 17 Not yet graded / 1 pts Exercise 1 - Question 17 Are there any special considerations to address when administering this drug in conjunction with the other medications currently in use? no No Question 18 Not yet graded / 1 pts Exercise 1 - Question 18 Identify any safety measures that should be observed after administration of this medication. may cause hypotension The medication may cause orthostatic hypotension, so care should be used when getting the patient up. Side rails should be used on his bed. The patient should be taught not to attempt to ambulate without assistance. Question 19 Not yet graded / 1 pts Exercise 1 - Question 19 Is it time for Harry George to be medicated again for pain? yes Yes Question 20 0 / 1 pts Click Return to Room 401. Then click Take Vital Signs. Exercise 1 - Question 20 What are Harry George's vital signs? (Note: Exact findings will vary depending on the virtual time at which they are taken.) BP: -151/93 SpO2: -90 T: -99.3 HR: -94 RR: -28 Pain: -8/10 1: -151/93 ~151/93 2: -90 ~90 3: -99.3 ~99.3 4: -94 ~94 5: -28 ~28 6: -8/10 ~8/10 Question 21 Not yet graded / 1 pts Exercise 1 - Question 21 What impact has Harry George's pain had on his vital signs? blood pressure and heart rate are elevated His blood pressure and heart rate are elevated. Question 22 Not yet graded / 1 pts Exercise 1 - Question 22 Are Harry George's vital signs within acceptable limits to administer the drug that has been ordered to manage his pain? yes Yes Question 23 Not yet graded / 1 pts Exercise 1 - Question 23 If Harry George is unable to take his prescribed medications, what action(s) would be appropriate? contact the physian The physician could be contacted to discuss the patient's continued complaints of pain. The nurse could also attempt to use nonpharmacologic measures to reduce the patient's pain. Lesson 08 - Osteoarthritis and Total Knee Replacement Due No due date Points 40 Questions 40 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 5,725 minutes 5 out of 40 ** Some questions not yet graded Score for this quiz: 5 out of 40 * Submitted Aug 24 at 2:45pm This attempt took 5,725 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 15 minutes to complete. Exercise 1 - Question 1 Briefly describe the pathophysiology of OA. (Hint: See Chapter 18 in your textbook.) The pathogenesis of OA involves a degradation of cartilage and remodeling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells in the surrounding tissues. OA is characterized by progressive deterioration and loss of cartilage in one or more joints (articular cartilage). The normal bluish-white, translucent cartilage becomes opaque and yellow-brown in color. As cartilage and the bone beneath the cartilage begin to erode, the joint space narrows and osteophytes (bone spurs) form. Fissures, calcifications, and ulcerations develop and the cartilage thins. Inflammatory cytokines enhance tissue deterioration. Weight-bearing joints (hips and knees), the vertebral column, and the hands are primarily affected because they are used most often or bear the mechanical stress of body weight. Question 2 1 / 1 pts Exercise 1 - Question 2 Which are considered to be causative factors related to the occurrence of primary osteoarthritis? Select all that apply. Aging Genetic changes Obesity Joint trauma Autoimmune factors Medication usage Question 3 Not yet graded / 1 pts Exercise 1 - Question 3 What are the clinical manifestations of OA? Pain. Affected joints might hurt during or after movement. Stiffness. Joint stiffness might be most noticeable upon awakening or after being inactive. Tenderness. ... Loss of flexibility. ... Grating sensation. ... Bone spurs. ... Swelling. Chronic joint pain and stiffness Crepitus Enlarged, hard joints Heberden’s nodes Bouchard’s nodes Joint effusions Loss of function Muscle atrophy from disuse secondary to pain Loss of function/decreased mobility Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 What laboratory and/or radiographic testing is used in the diagnosis of OA? (Hint: See Chapter 18 in your textbook.) There are no blood tests that diagnose osteoarthritis. If a joint is particularly swollen, a doctor may need to drain fluid from that joint. Tests can be performed on the fluid to look for clues for other types of arthritis, such as gout Erythrocyte sedimentation rate (ESR); normal or slightly elevated with OA High-sensitivity C-reactive protein; normal or slightly elevated with OA X-rays; structural joint changes Magnetic resonance imaging (MRI); determine vertebral or knee involvement Question 5 Not yet graded / 1 pts Exercise 1 - Question 5 How do primary and secondary osteoarthritis differ? This type of osteoarthritis is typically seen in people above the age of 55. It is believed that if we all live long enough, at some point, everybody will be affected by primary osteoarthritis. Secondary Osteoarthritis: Osteoarthritis in this form develops due to a specific cause such as injury or another disease. Primary osteoarthritis is related to a lost of joint function that is a normal part of aging or genetic factors. Secondary osteoarthritis results because of other disease processes or injury, such as trauma or obesity. Question 6 1 / 1 pts Exercise 1 - Question 6 What metabolic disorders are associated with the development of osteoarthritis? Select all that apply. Diabetes mellitus Sickle cell anemia Hypertension Right-sided heart failure Paget's disease Hemophilia Question 7 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click on Go to Nurses’ Station. Click on Chart and then on 404. Click on History and Physical. Exercise 2 - Question 1 According to the Plan at the bottom of the History and Physical, why was Clarence Hughes admitted to the hospital? he has degenative joint disease and osteoarthritis causing pain in both knees To undergo an elective left total knee replacement Question 8 Not yet graded / 1 pts Exercise 2 - Question 2 Describe the symptoms that brought Clarence Hughes to this point? arthroscophy done 6 years ago Several-year history of degenerative joint disease and OA causing chronic pain in both knees that has become progressively worse over time. The left knee has reached a point where it is affecting mobility and overall quality of life. Question 9 Not yet graded / 1 pts Exercise 2 - Question 3 According to the History and Physical, what medications and/or treatments were used to treat Clarence Hughes before he elected to have surgery? arthroscopy done 6 years ago, she has been taking celecoxib 100 mg po 2x Clarence Hughes had an arthroscopy done 6 years ago, which showed arthritic changes at that time. He has been taking celecoxib 100 mg PO twice a day. Question 10 1 / 1 pts Exercise 2 - Question 4 Which type of osteoarthritis does Clarence Hughes have? Primary Secondary Question 11 Not yet graded / 1 pts Exercise 2 - Question 5 Explain the rationale for performing a TKA/TKR on this patient. Total knee replacement is one option to relieve pain and to restore function to an arthritic knee. The most common reason for knee replacement is that other treatments (weight loss, exercise/physical therapy, medicines, injections, and bracing) have failed to relieve arthritis-associated knee pain. Joint pain has become progressively worse over time despite medication therapy and activity, mobility, and quality of life have been greatly affected. Question 12 Not yet graded / 1 pts Click on Surgical Reports. Exercise 2 - Question 6 How does the report of operation describe the surgical procedure performed on Clarence Hughes? An incision was made on the left knee. An incision was made into the lateral aspect of the left knee opening into the fascia. #4 femur, #3 tibia, and 29-mm patellar appliances were inserted in the usual fashion. The joint was irrigated with 2 liters of sterile irrigant; a Hemovac drain was inserted. Wound was closed with sutures. Question 13 Not yet graded / 1 pts Exercise 2 - Question 7 How would the minimally invasive surgical procedure differ? In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. In general, minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications. Minimally invasive surgery may be performed using a short incision and special instruments to spare muscle and other soft tissue. Question 14 Not yet graded / 1 pts Exercise 2 - Question 8 What was Clarence Hughes’ estimated blood loss (EBL)? 150 mL Question 15 Not yet graded / 1 pts Click on Physician’s Orders. Scroll down to read the orders for Sunday 1600. Exercise 2 - Question 9 What frequent assessments are ordered? Describe specifically how these assessments are completed and what the nurse is looking for. vital sighs every 4hrs assess color temperature capillary refill Vital signs every 4 hours including circulation, motion, and sensation checks. The nurse will need to assess color, temperature, peripheral pulses, and capillary refill of lower extremities; ask the patient to wiggle toes bilaterally; and assess the patient's ability to know when the nurse is touching his lower extremities. The nurse is monitoring for any decrease in circulation, movement, or sensation that could occur secondary to bleeding or swelling at the surgical site. The operative leg should be compared with the nonoperative leg. Question 16 Not yet graded / 1 pts Exercise 2 - Question 10 What type of surgical drain has been placed in Clarence Hughes' incision? Hemovac drain Question 17 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on EPR and Login. Select 404 from the Patient drop-down menu and Intake and Output from the Category drop-down menu. Exercise 2 - Question 11 List the amount of drainage recorded for drain 1 (Hemovac) in the immediate postoperative period for Sunday at 2300 and Monday at 0700. Sunday 2300 Monday 0700 Sunday 2300: 80ml Monday 0700:60ml Sunday 2300: 80 mL Monday 0700: 60 mL Question 18 1 / 1 pts Exercise 2 - Question 12 Indicate whether the following statement is true or false. The amount of drainage to the Hemovac has increased since Clarence Hughes was admitted to the unit. True False Question 19 Not yet graded / 1 pts Click on Return to Nurses' Station. Click on Chart and then on 404. Click on Physician's Notes. Scroll to and review the note for Mon 0730. Exercise 2 - Question 13 What is the status of the Hemovac at this time? How does the physician describe the dressing and/or amount of drainage? The Hemovac removed; dressing intact with minimal drainage. The Hemovac removed; dressing intact with minimal drainage. Question 20 Not yet graded / 1 pts Click on Physician’s Orders. Scroll down to read the orders for Monday 0715. Exercise 2 - Question 14 What is ordered to be applied to the operative knee? Explain the basic use of this device. (Hint: See Chapter 18 in your textbook.) Continous passive motion (CPM)machine: keeps the prosthetic knee in motion and prevents the formation of scar tissue, Continuous passive motion (CPM) machine; keeps the prosthetic knee in motion and prevents the formation of scar tissue, which could impede mobility of the knee and exacerbates postoperative pain. Question 21 Not yet graded / 1 pts Exercise 2 - Question 15 According to the physician's notes, how should Clarence Hughes' operative leg be positioned when the device that you identified in question 14 is not in use? Are there any other positioning precautions that should be taken into consideration? (Hint: See Chapter 18 in your textbook.) SCDs when patient is not in the CPM device The operative leg should be flat with a pillow under the heel. Additionally, the nurse might consider placing the operative leg in a neutral position, ensuring that it is not rotated internally or externally and not hyperextended. Question 22 Not yet graded / 1 pts Click on Laboratory Reports. Exercise 2 - Question 16 What was Clarence Hughes' hemoglobin (Hgb) and hematocrit (Hct) values on Tuesday at 0600 and Monday at 0600? Tuesday at 0600 : Hgb: 9.6;Hct 32% Monday at 0600: hgb 7.4; Hct:26% Monday 0600—Hgb: 9.6; Hct: 32% Tuesday 0600—Hgb: 7.4; Hct: 26% Question 23 Not yet graded / 1 pts Click on Return to Nurse's Station. Click on EPR. Click on Login. Select 404 from the Patient drop-down menu and Intake and Output from the Category drop-down menu. Exercise 2 - Question 17 Calculate the intravenous (IV) fluid intake from the time that Clarence Hughes was admitted to the floor until Tuesday at 0600 using the total Intake for Sunday 2300, Monday 0700, Monday 1500, and Monday 2300. Then determine the total blood loss from surgery (EBL) plus the drainage you recorded for question 11 Total fluid intake Total blood loss Total fluid intake= 4853 ml Total blood loss=290ml Total fluid intake = 4853 mL (899 + 1364 + 1670 + 920) Total blood loss = 290 mL (150 + 80 + 60) Question 24 Not yet graded / 1 pts Exercise 2 - Question 18 Based on the information gathered in question 17, what might be the explanation for the drop in Hgb and Hct? Clarence Hughes’ admitting Hgb and Hct were below normal at 9.6 and 32%. His EBL was 150 mL and total drainage from Hemovac was 140 mL, resulting in a blood loss of only 290 mL. These factors alone should not account for a 2-g drop in the Hgb; however, coupled with postoperative IV hydration, Tuesday’s Hgb and Hct probably demonstrates a mixture of preexisting anemia, blood loss, and hemodilution. Question 25 Not yet graded / 1 pts Click on Return to Nurses' Station. Click on Chart and then on 404. Click on Physician's Orders. Scroll to and review the order for Tue 1000. Exercise 2 - Question 19 What was ordered to correct the decreased hemoglobin? 2 units of packed red blood cells to be transfused today Question 26 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click on Get Report. Exercise 3 - Question 1 What are your concerns for Clarence Hughes after receiving this report? left knee pain 8/10 increased swelling of the left knee above compression bandage constipation IV site red with pain Left knee pain 8/10 Increased swelling of left knee above compression bandage Constipation IV site red with pain (IV discontinued but still need to watch site for phlebitis) Question 27 Not yet graded / 1 pts Click on Go to Nurses’ Station. Click on 404 at the bottom of your screen. Click on Patient Care and then on Physical Assessment. Complete a focused assessment by clicking on the body system categories (yellow buttons) and subcategories (green buttons). Exercise 3 - Question 2 Document the findings of your focused assessment for the integumentary, musculoskeletal, neurovascular, gastrointestinal and respiratory systems below. Integumentary Musculoskeletal Neurovascular Gastrointestinal Respiratory Integumentary: Left leg swollen, though without redness; wrapped in gauze dressing and Ace wrap for support. Left leg incision well approximated, mildly swollen at site; no redness or drainage. Musculoskeletal: Mildly decreased range of motion (ROM) and movement in right leg with some knee stiffness. Impaired ROM and movement in left leg. Slow, steady gait. Neurovascular: Capillary refill less than 3 seconds. Pulses 2+ bilaterally. Unable to assess popliteal pulse in left leg. Gastrointestinal: Bowel sounds in all 4 quadrants. No tenderness or masses palpated. Respiratory: Regular and even respiratory effort. Bilateral breath sounds clear and equal to auscultation. No cough. SpO2 93% in room air. No adventitious lung sounds. No accessory muscle use. Question 28 Not yet graded / 1 pts Click on Clinical Alerts. Exercise 3 - Question 3 Based on the findings of your physical assessment and the information in the clinical alert, what would be your priority interventions? Medicate for pain and constipation.Closely observe increased swelling of the left knee. Consult doctor Medicate for pain and constipation. Closely observe increased swelling of the left knee. Consult with surgeon regarding concerns. Question 29 Not yet graded / 1 pts Click on Medication Room. Click on MAR to determine prn medications that have been ordered for Clarence Hughes to address his constipation and pain. (Note: You may click on Review MAR at any time to verify correct medication order. Click on the correct room number within the MAR. Remember to look at the patient name on the MAR to make sure you have the correct patient’s record. Click on Return to Medication Room after reviewing the correct MAR.) Click on Unit Dosage and then click on drawer 404. Select the medications you would like to administer. After each selection, click on Put Medication on Tray. When you are finished selecting medications, click on Close Drawer. Click on View Medication Room. Click on Automated System and then click on Login. On the next screen, specify the correct patient and drawer location. Select the medication you would like to administer and click on Put Medication on Tray. Repeat this process if you wish to administer other medications from the Automated System. When you are finished, click on Close Drawer. At the bottom right corner of the next screen, click on View Medication Room. From the Medication Room, click on Preparation (or on the preparation tray). From the list of medications on your tray, choose the correct medication to administer. Click on Prepare. Supply the information that the Preparation Wizard requests. Click on Next, specify the correct patient to administer this medication to, and then click on Finish. Repeat the previous three steps until all medications that you want to administer are prepared. You can click on Review Your Medications and then on Return to Medication Room when ready. Once you are back in the Medication Room, you may go directly to Clarence Hughes’ room by clicking on 404 at the bottom of the screen. Administer the medication, utilizing the six rights of medication administration. After you have collected the appropriate assessment data and are ready for administration, click on Patient Careand then on Medication Administration. Verify that the correct patient and medication(s) appear in the left-hand window. Click the down arrow next to Select. From the drop-down menu, select Administer and complete the Administration Wizard by providing any information requested. When the Wizard stops asking for information, click on Administer to Patient. Specify Yes when asked whether this administration should be recorded in the MAR. Finally, click on Finish. You will evaluate your performance in this area at the end of this exercise (see question 14). Exercise 3 - Question 4 What is missing from Clarence Hughes’ order for oxycodone with acetaminophen? What measures need to be taken? The dosage strength is not specified in either the MAR or in the physician’s order. The nurse would need to hold the medication and call the physician for clarification. Once the order is clarified, before administration, the nurse would need to calculate total dose of acetaminophen the patient has received for the day. Clarence Hughes has acetaminophen ordered for an elevated temperature, as well as the acetaminophen combined with the oxycodone. The total dose of acetaminophen should not exceed 4 grams from all sources. Question 30 Not yet graded / 1 pts Exercise 3 - Question 5 Based on the knowledge that most antacids frequently decrease absorption of other medications when concurrently administered, what options might the nurse employ to ensure adequate absorption of pain medication? (Hint: Look in the Drug Guide.) Pain relief Because pain relief is a priority over relief of constipation, the nurse should administer the analgesic, wait 2 hours, and then administer the milk of magnesia. This would allow adequate time for complete absorption of the analgesic and will not prolong the patient’s discomfort. Question 31 Not yet graded / 1 pts Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 0735: Empathy. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and on Nurse-Client Interactions to refresh the screen.) Exercise 3 - Question 6 The nurse attempts to appear empathetic by offering to listen to the patient’s concerns. Are her actions congruent with her verbal communication? Why or why not? no Although the nurse is very friendly and verbalizes understanding of patient’s request for oral laxative, planning to put patient on the CPM at the same time as administering pain medication does not allow time for the analgesic to begin it’s effect and does not demonstrate empathy for the patient’s pain. Question 32 Not yet graded / 1 pts Exercise 3 - Question 7 As a student nurse, what would you do differently? Ambulate at least 25-50 feet today. Up in chair twice a day. Administer pain medication and reassess in 30 to 60 minutes. Apply CPM once pain is better controlled. Question 33 Not yet graded / 1 pts Exercise 3 - Question 8 Identify potential complications related to Clarence Hughes' postoperative status and measures that can be implemented to prevent them. Document your plan of care below. Neurovascular compromise: Frequent assessments Ice to knee to minimize swelling Elevation of extremity Wound infection: Frequent assessments of wound/dressing and vital signs Aseptic technique when changing dressings and emptying drains Administer ordered antibiotics Decreased knee mobility: Maintain CPM as ordered Leg flat in bed with pillow under heal to maintain extension when not in CPM Venous thromboembolism (VTE): Frequent assessment of pulses and for calf pain and/or swelling Administer enoxaparin as ordered Early ambulation and leg exercises Elastic support hose on non operative extremity as ordered by physician Bleeding/anemia: Monitor wound drainage, report if greater than 50 mL/shift Monitor Hgb and Hct, report decrease Administer red blood cells as ordered Maintain fluid intake to decrease blood viscosity Nutrition/diet counseling for foods high in iron/protein Question 34 Not yet graded / 1 pts Click on Chart and then on 404. Click on Consultations. Exercise 3 - Question 9 What is physical therapy (PT) doing for Clarence Hughes? Working on gait training with walker, weight bearing, and assist of one person. Having Clarence Hughes perform therapeutic exercises, including ankle pumps, gluteal sets, and quad sets. Providing patient and family teaching regarding task performance. Question 35 Not yet graded / 1 pts Click on Physician’s Orders. Exercise 3 - Question 10 What is the patient's activity order for Wednesday morning? Ambulate at least 25-50 feet today. Up in chair at least twice a day. Question 36 Not yet graded / 1 pts Click on Physician's Orders. Scroll and review the order for Mon 0715. Exercise 3 - Question 11 What is Clarence Hughes' goal for CPM therapy today (postoperative day 3)? 75 degrees 75 degrees Question 37 Not yet graded / 1 pts Click on Nurse's Notes. Review the notes for Wednesday and Tuesday. Click on Nursing Admission. Scroll to page 12 and review Clarence Hughes' home environment. Exercise 3 - Question 12 Based on the orders and the patient's activity and home environment, do you think the ambulation goal and CPM goal are sufficient for this patient to be discharged tomorrow? Why or why not? (Hint: See Chapter 18 in your textbook.) with physical exercise The ambulation goal should be sufficient because Clarence Hughes has a first-floor bedroom and bathroom. According to the textbook, the goal of therapy is for the patient to walk independently with crutches, walker, or cane, and have adequate flexion in the operative knee. The patient is only at 75 degrees today, but that is an increase of 15 degrees from the previous day. Therefore it is likely that the patient will be able to reach the goal of 90 degrees on the day of discharge. Question 38 Not yet graded / 1 pts Click on Patient Education. Exercise 3 - Question 13 What teaching should be completed for Clarence Hughes before his discharge? incision care follow up with physian s may vary, but may include the following: Self-injection and medication education for enoxaparin and other home medications Ambulation and home maintenance needs Measures to promote knee mobility Incision care Follow-up visit with physician Signs and symptoms of complications related to wound healing, venous thromboembolism (VTE), etc. and what to do about them Follow-up physical therapy visits Home safety (e.g., pick up throw rugs, lighting in bathroom, etc.) Question 39 1 / 1 pts Exercise 3 - Question 14 In the absence of complications, total recovery after a TKA can be anticipated within what time period? 2 weeks 4 weeks 6 weeks 8 weeks Question 40 Not yet graded / 1 pts Now let’s see how you did during your earlier medication administration! Click on Leave the Floor. From the Floor Menu, click on Look at Your Preceptor’s Evaluation, then click on Medication Scorecard. Exercise 3 - Question 15 Disregard the report for the routine scheduled medications, and instead note below whether or not you correctly administered the appropriate prn medications. If not, why do you think you were incorrect? According to Table C in this scorecard, what resources should be used and what important assessments should be completed before administering these medications? Did you utilize these resources and perform these assessments correctly? The student should have administered magnesium hydroxide 30 mL for complaints of constipation. The patient also had bisacodyl docusate ordered, which would be appropriate for constipation, but the patient requested an oral medicine. Before administering this medication, the student should have checked the chart to look at expired MARs in order to verify timing of last dose, before giving a prn medication. The student should also have assessed the patient’s allergies and name band. The student should NOT have administered a pain medication. Oxycodone with acetaminophen is available in two different dosage strengths in the automated system, and the order is missing dosage strength. Lesson 03 - Fluid Imbalance Due No due date Points 18 Questions 18 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 501 minutes 1 out of 18 ** Some questions not yet graded Score for this quiz: 1 out of 18 * Submitted Aug 21 at 10:30pm This attempt took 501 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 30 minutes to complete. Exercise 1 - Question 1 Describe the function of water in the body. (Hint: See Chapter 11 in your textbook.) Your body uses water in all its cells, organs,and tissues to help regulate its temperature and maintain other bodily functions. Because your body loses water through breathing, sweating, and digestion. Its important to rehydrate by drinking fluids. Body water delivers dissolved nutrients, electrolytes, and other substances to organs, tissues, and cells. Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 Identify the two main water (fluid) compartments in the body and describe the composition of each. Fluid Compartments in the Human Body. The intracellular fluid (ICF) is the fluid within cells. The interstitial fluid (IF) is part of the extracellular fluid (ECF) between the cells. Blood plasma is the second part of the ECF. Extracellular fluid (ECF)—the fluid outside the cells; includes interstitial fluid (fluid between cells), blood, lymph, bone, and connective tissue water; also includes transcellular fluids (fluids in special body spaces), cerebrospinal fluid, synovial fluid, peritoneal fluid, and pleural fluid; accounts for about 1/3 (about 15 L) of total body water Intracellular fluid (ICF)—the fluid inside of cells; accounts for the remaining 2/3 (about 25 L) of total body water Question 3 Not yet graded / 1 pts Exercise 1 - Question 3 Describe the pathophysiology for dehydration and identify key clinical manifestations. The negative fluid balance that causes dehydration results from decreased intake, increased output (renal, gastrointestinal [GI], or insensible losses), or fluid shift (ascites, effusions, and capillary leak states such as burns and sepsis). Pathophysiology: In dehydration, fluid intake is less than what is needed to meet the body’s fluid needs, resulting in a fluid volume deficit. It is a condition rather than a disease and can be caused by many factors. Dehydration may be an actual decrease in total body water caused by either too little intake of fluid or too great a loss of fluid. It also can occur without an actual loss of total body water, such as when water shifts from the plasma into the interstitial space. This condition is called relative dehydration. Clinical Manifestations: Weight loss Orthostatic hypotension Tachycardia Weak peripheral pulses Flat neck and hand veins Increased respiratory rate Poor skin turgor Skin dry and scaly Mucous membranes cracked and fissured with thick pastelike coating Alterations in mental status Low-grade fever Decreased urine output Dark amber, concentrated urine Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 Describe the pathophysiology of fluid volume overload and identify the key clinical manifestations. Fluid overload or volume overload (hypervolemia), is a medical condition where there is too much fluid in the blood. Excess fluid, primarily salt and water, builds up throughout the body resulting in weight gain. You will see the following signs or symptoms: Noticeable swelling in the legs and arms (peripheral edema) Pathophysiology: Fluid overload may be either an actual excess of total body fluid or a relative fluid excess. The most common type of fluid overload is hypervolemia because the problem results from excessive fluid in the extracellular fluid (ECF) space. The conditions leading to fluid overload are related to excessive intake or inadequate excretion of fluid. Fluid overload can lead to heart failure and pulmonary edema. Clinical Manifestations: Tachycardia Bounding, full pulse Hypertension Decreased pulse pressure Distended neck and hand veins Weight gain Increased respiratory rate Shallow respirations Dyspnea with exertion or when lying down Moist crackles Pitting edema Skin pale and cool to touch Altered level of consciousness Headache Visual disturbances Skeletal muscle weakness Paresthesias Increased gastrointestinal (GI) motility Enlarged liver Question 5 1 / 1 pts Exercise 1 - Question 5 Match each term related to fluid volume regulation with its corresponding definition listed below. (A) The free movement of particles (solute) across a permeable membrane from an area of higher concentration to an area of lower concentration (B) The movement of fluid through a cell or blood vessel membrane because of hydrostatic pressure differences on both sides of the membrane (C) The movement of water only through a selectively permeable (semipermeable) membrane (D) The pressing of water molecules against confining walls (E) The number of milliosmoles in a kilogram of solution (F) The number of milliosmoles in a liter of solution (G) The particles dissolved or suspended in water (H) A fluid with a solute concentration equal to the osmolarity of normal body fluids or normal saline, about 300 mOsm/L (I) Diffusion across a cell membrane that requires the assistance of a membrane-altering system (J) A hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased (K) A fluid with an osmolarity greater than greater than 300 mOsm/L (L) A fluid with an osmolarity less than that of normal body fluids (less than 270 mOsm/L) (M) A hormone produced in the brain that is stored in and released from the posterior pituitary gland in response to changes in blood osmolarity Hydrostatic pressure D Filtration B Diffusion A Osmolarity F Aldosterone J Hypotonic L Osmosis C Antidiuretic hormone (ADH) M Isotonic H Osmolality E Solute G Facilitated diffusion I Hypertonic K Question 6 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 20 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses' Station. Click on Chart and then on 403. Click on Emergency Department and review the record. Exercise 2 - Question 1 Record findings below that support the diagnosis of dehydration. bp nausea Blood pressure (BP) 92/54, pulse 124 Complaints of nausea/vomiting Weakness Tacky mucous membranes Decreased urine output Question 7 Not yet graded / 1 pts Click on Nursing Admission. Exercise 2 - Question 2 Are there any additional findings noted on this document that support the diagnosis of dehydration? If so, list them below. blood pressure, pulse, skin turgor Oral mucosa slightly pale and tacky Skin turgor with slight tenting on forearms and sternum Orthostatic BP readings—improved but still a drop of 10 mm Hg from lying to standing 1+ peripheral pulses Question 8 Not yet graded / 1 pts Click on Laboratory Reports. Exercise 2 - Question 3 Record all pertinent results for Monday at 2200 below and describe the significance of each result in relation to the diagnosis of dehydration. DAY/TIME: Mon 2200 HEMATOLOGY WBC 7.1 RBC 3.8 HEMOGLOBIN 9.1 HEMATOCRIT 30 MCV 82.3 PLATELETS 128 DIFF: NEUTROPHIL SEGS52 NEUTROPHIL BANDS 4 LYMPHOCYTES 39 MONOCYTES 9.2 EOSINOPHILS 2.0 BASOPHILS 1.4 RETICULOCYTES1.4% ERYTHROCYTE SEDIMENTATION RATE 18 mm/hr NEUTROPHILS 68.6 CHEMISTRY GLUCOSE 98 SODIUM 147 POTASSIUM 3.3 CHLORIDE 107 CO2 28 CREATININE 0.8 BUN 34 URIC ACID CALCIUM PHOSPHORUS MAGNESIUM BILIRUBIN (TOTAL) 0.8 PROTEIN 5.5 Blood urea nitrogen (BUN) 34 (elevated) with normal creatinine—demonstrates hypovolemia/dehydration Sodium slightly elevated at 147—secondary to hemoconcentration Urine specific gravity 1.05—elevated, demonstrating concentrated urine secondary to dehydration Hemoglobin and hematocrit are low—does not fit the picture of dehydration; may be related to another disease process, perhaps malignancy? Potassium low at 3.3—hypokalemia secondary to vomiting Question 9 Not yet graded / 1 pts Click on History and Physical. Exercise 2 - Question 4 Based on your review of Piya Jordan’s History and Physical, what were the contributing factors leading to her dehydration? Patient is dehydrated and complains of generalized abdominal pain. CT of abdomen shows mass in right lower quadrant of abdomen. Nausea and vomiting for several days. Nausea and vomiting for several days following weeks of poor appetite and increasing weakness Question 10 Not yet graded / 1 pts Click on Physician's Orders. Exercise 2 - Question 5 Identify orders on Monday at 2115 that represent appropriate management strategies for the treatment of dehydration and write your findings below. 2-lead EKG. Orthostatic blood pressure readings. Continuous cardiac monitoring. Oxygen 2L flow by nasal cannula. Labs: Complete blood count, urinalysis, electrolytes (Chem 7), lipase, amylase, liver function tests, PT/INR, Digoxin level. X-ray: Chest PA and lateral, KUB and upright. IV Normal saline one liter bolus. Preoperative orders for Monday 2115: IV normal saline, 1 liter bolus Assess orthostatic BP readings Monitor electrolytes Question 11 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Now you will similar questions related to fluid balance for another patient and compare your findings. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Patricia Newman (Room 406). Click on Go to Nurses’ Station. Click on Chart and then on 406. Click on Emergency Department and review this record. Exercise 3 - Question 1 Identify assessment findings for Patricia Newman related to fluid balance and record them below. How do these findings differ from those for Piya Jordan? Are there any similarities? Temp 100.9 bp 164/90 and Hr 106, no edema, mucous membrane moist. patricias bp is higher than piya Patricia Newman’s findings: T 100.9 F, BP 164/90, HR 106; no edema; mucous membranes moist Differences/similarities to Piya Jordan’s findings: Patricia Newman's BP is much higher. Her mucous membranes were normal, whereas Piya Jordan demonstrated dehydration. Patricia Newman has an elevated temperature. Neither patient has edema. Question 12 Not yet graded / 1 pts Click on Nursing Admission. Exercise 3 - Question 2 Are there any additional findings noted on this document related to fluid balance and/or imbalance? If so, list them below. How do they compare with findings for Piya Jordan? Patricia Newman’s findings: skin turgor, slight tenting; 2+ pulses; no jugular vein distention (JVD); no edema Comparison with Piya Jordan’s findings: same, except that Patricia Newman’s pulses are stronger, denoting higher blood pressure Question 13 Not yet graded / 1 pts Click on Laboratory Results. Exercise 3 - Question 3 Record all pertinent results from Tuesday at 2300 and Wednesday at 0500 below and describe the significance of each result in relation to fluid balance. Describe any differences between these findings and Piya Jordan's findings. Hemoglobin -15 Hematocrit-45 Potassium:3.2 low Hemoglobin - 15 (WNL) Hematocrit—45 (WNL) Serum sodium level—140 (WNL) Potassium—3.2 (low) BUN—18 (WNL) No urinalysis available Piya Jordan’s serum electrolytes and BUN demonstrated a fluid volume deficit. Patricia Newman’s lab results are normal, denoting normal fluid balance, except for hypokalemia, which could be dilutional if patient has fluid overload or can be decreased with the use of diuretic therapy to treat fluid volume excess. Question 14 Not yet graded / 1 pts Exercise 3 - Question 4 Based on your findings, does Patricia Newman have a fluid imbalance? If so, what type? tenting yes The only abnormal assessment finding related to fluid imbalance for Patricia Newman is slight tenting. Slight tenting may be related to slight dehydration related to insensible fluid loss from fever. Also, patient has been taking a diuretic, which increases the risk for dehydration if homeostasis is interrupted. Patricia Newman is at risk for fluid overload with hypertension when fever subsides if the diuretic is not restarted. Question 15 Not yet graded / 1 pts Exercise 3 - Question 5 What are the contributing factors for this patient’s potential or actual fluid imbalance? fever,medications Fever, diuretic use Question 16 Not yet graded / 1 pts Click on History and Physical. Exercise 3 - Question 6 What coexisting illness might have an impact on the selection and rate of IV fluid therapy? hypertension Hypertension. Fluid administered to treat pneumonia may increase ECF volume and increase BP—will need to monitor. Do not want to administer hypertonic fluids because they would pull more fluid into the vascular space. Question 17 Not yet graded / 1 pts Exercise 3 - Question 7 Develop an appropriate plan of care for the patient with dehydration. Include nursing diagnoses, assessment parameters, diet therapy, and drug therapy. excess fluid volume risk for electrolyte imbalancev risk for hypertension vital signs,weight, I&O Nursing diagnoses: Deficient fluid volume related to excessive fluid loss or inadequate fluid intake Decreased cardiac output related to decreased plasma volume Impaired oral mucous membrane related to inadequate oral secretions Confusion (acute or chronic) related to neurologic changes Risk for falls related to orthostatic (postural) hypotension Risk for impaired skin integrity related to changes in fluid status and skin turgor Assessment parameters: Vital signs, including orthostatic BP readings Daily weight Intake and output Hourly urine output Neuro status and muscle strength Peripheral pulses Skin turgor Serum electrolytes Hemoglobin, hematocrit, serum osmolality, glucose, protein, and BUN Diet therapy: Oral fluid replacement therapy Divide intake over 24 hours Specific type depends on electrolyte levels Offer snacks as appropriate Appropriate for mild to moderate dehydration Drug therapy: IV fluid replacement Electrolytes replaced as needed Appropriate for moderate to severe dehydration Antidiarrheal drugs if diarrhea causing dehydration Antimicrobial therapy if bacterial diarrhea Antiemetics to control vomiting Antipyretics to reduce fever Question 18 Not yet graded / 1 pts Exercise 3 - Question 8 Develop a plan of care for the patient with fluid volume overload. excess fluid volume risk for electrolyte imbalancev risk for hypertension vital signs,weight, I&O Nursing diagnoses: Excess fluid volume related to compromised regulatory mechanisms Deficient knowledge (fluid restrictions, drug therapy, and manifestations of fluid excess) related to lack of exposure or lack of interest in learning Risk for electrolyte imbalances Risk for hypertension Risk for pulmonary edema Assessment parameters: Vital signs Daily weight Intake and output Neuro status Skin turgor Serum electrolytes Skin for edema Lung sounds Muscle strength Peripheral pulses Diet therapy: Fluid restriction Sodium restriction Drug therapy: Diuretics Lesson 07 - Perioperative Care Due No due date Points 38 Questions 38 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 295 minutes 7.25 out of 38 ** Some questions not yet graded Score for this quiz: 7.25 out of 38 * Submitted Aug 28 at 5:37pm This attempt took 295 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Virtual Hospital Exercise This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses’ Station. Click on Chart and then on 403. Click on Emergency Department and review the record. Exercise 1 - Question 1 What complaints (problems) brought Piya Jordan to the Emergency Department? Abdominal pain, nausea, vomiting Abdominal pain, nausea, vomiting, progressive weakness Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 What were her primary and secondary diagnoses on admission? Primary: Abdominal pain, nausea, vomiting, dehydration Secondary: R/O bowel obstruction; abdominal mass Primary diagnosis: abdominal pain, nausea, vomiting, dehydration Secondary diagnosis: rule out (R/O) bowel obstruction, abdominal mass Question 3 0.5 / 1 pts Click on Nursing Admission. Click on History and Physical. Exercise 1 - Question 3 Which findings from the preoperative health history increase Piya Jordan's risk for surgical complications? Select all that apply. (Hint: See Table 14-3.) Age 68 years Arthritis in knees Atrial fibrillation Celecoxib 300 mg every 12 hours Digoxin 0.125 mg daily Stress incontinence Warfarin 5 mg daily Question 4 Not yet graded / 1 pts Now click on Laboratory Report. Exercise 1 - Question 4 Record Piya Jordan's CBC results from Monday at 2200. Insert an asterisk after any results that are abnormal. White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin Hematocrit Platelets HEMATOLOGY WBC 7.1 RBC 3.8 HEMOGLOBIN 9.1 HEMATOCRIT 30 MCV 82.3 PLATELETS 128 White blood cell count (WBC): 7.1 Red blood cell count (RBC): 3.8* Hemoglobin: 9.1* Hematocrit: 30* Platelets: 128* Question 5 Not yet graded / 1 pts Exercise 1 - Question 5 Record Piya Jordan's electrolyte results from Monday at 2200. Insert an asterisk after any results that are abnormal. Glucose Sodium Potassium GLUCOSE 98 SODIUM 147 POTASSIUM Glucose: 98 Sodium: 147* Potassium: 3.3* 3.3 Question 6 Not yet graded / 1 pts Exercise 1 - Question 6 Record Piya Jordan's renal results from Monday at 2200. Insert an asterisk after any results that are abnormal. Blood urea nitrogen (BUN) Creatinine CREATININE 0.8 BUN 34 Blood urea nitrogen (BUN): 34* Creatinine: 0.8 Question 7 Not yet graded / 1 pts Exercise 1 - Question 7 Record Piya Jordan's urinalysis results from Monday at 2200. Insert an asterisk after any results that are abnormal. Urine glucose Blood Protein Leukocytes Urine glucose- Neg Blood-Neg Protein-neg Leukocytes -neg Urine glucose: Negative Blood: Negative Protein: Negative Leukocytes: Negative Question 8 Not yet graded / 1 pts Exercise 1 - Question 8 Record Piya Jordan's coagulation test results from Monday at 2200. Insert an asterisk after any results that are abnormal. Prothrombin time (PT) International normalized ratio (INR) Prothrombin time (PT)-19.8 International normalized ratio (INR)-2.1 Prothrombin time (PT): 19.8* International normalized ratio (INR): 2.1* Question 9 Not yet graded / 1 pts Exercise 1 - Question 9 Record Piya Jordan's blood type results from Tuesday at 0630. blood type a positive Blood type: A+ Question 10 Not yet graded / 1 pts Exercise 1 - Question 10 Are any of Piya Jordan’s laboratory results abnormal or of concern for a patient preparing to undergo surgery? Explain. (Hint: See Chapter 14 in your textbook.) Her hemoglobin is low hematocrit. The low hemoglobin and hematocrit, along with low platelet count and elevated PT/INR, increase the patient’s risk for bleeding and hypoxemia during and after surgery. The low potassium level should also be corrected before surgery to decrease the risk for cardiac dysrhythmias during surgery. The patient is dehydrated, as evidenced by elevated sodium and BUN levels—fluids should be administered before surgery as well. Question 11 1 / 1 pts Click on Surgical Reports. Exercise 1 - Question 11 Which best describes the type of surgery Piya Jordan had performed? Diagnostic Curative Restorative Palliative Cosmetic Question 12 Not yet graded / 1 pts Exercise 1 - Question 12 Piya Jordan is 68 years of age. Her age increases her risk for the development of postoperative complications. For each body system below, list the age-related physiologic changes that increase her risks for complications and may delay her recovery. Then identify one to two nursing interventions that may be implemented to reduce complications. Cardiovascular system Respiratory system Renal system Neurologic system Integumentary system Cardiovascular system Physiologic change: Decreased cardiac output Increased blood pressure Reduced peripheral circulation Nursing interventions: Monitor vital signs, peripheral pulses, and capillary refill Sequential compression devices (SCDs) Antiembolism stockings Respiratory system Physiologic change: Reduced vital capacity Loss of lung elasticity Decreased oxygenation of blood Nursing interventions: Incentive spirometry Turn, cough, and deep breathing exercises Early ambulation Renal system Physiologic change: Decreased blood flow to kidneys Reduced ability to excrete waste products Decline in glomerular filtration rate (GFR) Nocturia Nursing interventions: Monitor intake and output Assess hydration status Monitor electrolyte status Neurologic system Physiologic change: Sensory deficits Delayed reaction time Reduced ability to adjust to changes in surroundings Nursing interventions: Allow extra time for teaching Integumentary system Physiologic change: Less subcutaneous fat Delayed skin healing Increased risk for infection Nursing interventions: Assess incision Frequently change positions Question 13 0.75 / 1 pts Exercise 1 - Question 13 When reviewing the medication list of a patient scheduled for surgery, which medication types are associated with an increased risk for complications? Select all that apply. Antibiotics Nonsteroidal antiinflammatory agents Anticoagulants Diuretics Antihypertensives Tricyclic antidepressants Question 14 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses’ Station. Click on Chart and then on 403. Click on Consents. Exercise 2 - Question 1 For what procedure(s) has Piya Jordan given written consent? blood transfusion Blood transfusion Question 15 Not yet graded / 1 pts Exercise 2 - Question 2 Who is responsible for providing detailed information about the procedure(s) for which Piya Jordan has given consent? Health care provider The surgeon or physician Question 16 1 / 1 pts Exercise 2 - Question 3 Which are nursing responsibilities in regard to obtaining informed consent? Select all that apply. (Hint: See Chapter 14 in your textbook.) Clarify information presented by the physician Witness patient signature Provide detailed information about the risks and benefits of the planned procedure Ensure the patient has complete understanding about the procedure Question 17 Not yet graded / 1 pts Now click on Physician's Orders. Exercise 2 - Question 4 Look at the orders for Tuesday 0130. What consent was ordered? consent of surgery for colectomy. Surgical consent for colectomy, possible colostomy Question 18 Not yet graded / 1 pts Exercise 2 - Question 5 By when does this consent need to be obtained? before patients recieves any preoperative sedation Before patient receives any preoperative sedation Question 19 Not yet graded / 1 pts Exercise 2 - Question 6 What is the purpose of the mineral oil enema that was ordered to be given to Piya Jordan? for bowel elimination before surgery For bowel evacuation before major abdominal surgery; to prevent injury to colon and reduce number of intestinal bacteria Question 20 Not yet graded / 1 pts Exercise 2 - Question 7 What diet has the physician ordered preoperatively? What is the purpose for this diet order? NPO Nothing by mouth (NPO)—to decrease volume of stomach contents and decrease risk for aspiration during anesthesia and surgery Question 21 1 / 1 pts Exercise 2 - Question 8 The American Society of Anesthesiologists recommends an NPO time of at least 6 hours for easily digested solid foods and 2 hours for clear liquids before surgery. 1: 6 2: 2 Question 22 Not yet graded / 1 pts Exercise 2 - Question 9 What is the rationale for giving Piya Jordan a unit of fresh frozen plasma preoperatively? (Hint: See Chapter 40 in your textbook.) will lower her bleeding Fresh frozen plasma (FFP) contains clotting factors, which will minimize bleeding risk in patient who has an elevated PT/INR before surgery. Question 23 Not yet graded / 1 pts Exercise 2 - Question 10 How long before surgery can an autologous blood transfusion be obtained? What is an advantage of this type of blood tranfusion? several weeks like7, An autologous blood transfusion may be obtained a few weeks before surgery. Using a patient's own blood eliminates the risk of transmitting bloodborne illnesses. Question 24 Not yet graded / 1 pts Exercise 2 - Question 11 What is the rationale for ordering a dose of cefotetan on call to the operating room for Piya Jordan? Is this a safe order to administer to her? Explain why or why not. (Hint: See Chapter 14 in your textbook.) it is an antibiotic and minimizes the risk of infection. Cefotetan is a cephalosporin antibiotic given preoperatively to minimize the risk for infection during and after major surgery. It is not a safe order for Piya Jordan because she has a documented allergy to cephalosporins. Question 25 Not yet graded / 1 pts Click on Surgical Reports. Scroll down to the Preoperative Checklist. Exercise 2 - Question 12 Using Table 14-4 in your textbook, list the items that should be considered when planning preoperative teaching. Place an asterisk by those items that were NOT covered, according to Piya Jordan's Preoperative Checklist. Fears and anxieties* Surgical procedure Preoperative routines (e.g., NPO, blood samples,* showering*) Invasive procedures (e.g., lines, catheters*) Coughing, turning, deep breathing Incentive spirometer (how to use; how to tell when used correctly*) Lower extremity exercises* Stockings and pneumatic compression devices* Early ambulation* Splinting Pain management Question 26 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Clarence Hughes’ scheduled surgery has been completed. You will be reviewing the care already given to him and planning and evaluating care for him during the immediate postoperative period. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click on Go to Nurses’ Station. Click on EPR and then on Login. Select 404 from the Patient drop-down menu. From the Category drop-down menu, select and review Vital Signs, Respiratory, Neurologic, Integumentary, IV, Wounds and Drains, and any other EPR categories necessary to the following question. Exercise 3 - Question 1 A postoperative patient requires an immediate focused assessment on arrival to the medical-surgical nursing unit. Document the assessment findings recorded by the nurse on Sunday at 1600 when Clarence Hughes arrived on the medical-surgical unit. Be sure to check the following key assessment areas in the EPR: Respiratory, Neurologic, Vital Signs, IV, and Wounds and Drains. (Note: If information is not explicitly available in the EPR, list where information can be found based on codes.) Respiratory Neurologic Vital Signs IV Wounds and Drains Respiratory: rate is 18, lung sounds are clear Neurologic: orientedto person, place, situation, and time, speech normal.Cognition within normal limits Vital Signs: T;97.5 HR 104 BP 120/74 IV: 18 guage peripheral IV Wounds and Drains: Gauze dressing intact with small amount sanguinous drainage Respiratory: Respiratory rate 18. Lung sounds clear. Regular and even respirations. Lungs clear to auscultation. Neurologic: Oriented to person, place, situation, and time. Speech normal. Cognition within normal limits. Vital Signs: T 97.5, HR 104, BP 120/74 IV: 18-gauge peripheral IV angiocatheter in left forearm. Solution #1 infusing at 125 mL/hr; mixture, see notes and/or orders Solution #2 infusing; mixture, see notes and or orders; see orders for rate. Wounds and Drains: Gauze dressing intact with small amount sanguinous drainage. Hemovac to self-bulb suction with red drainage. Question 27 Not yet graded / 1 pts Exercise 3 - Question 2 How frequently did the nurse assess Clarence Hughes’ vital signs after his arrival on the unit? How often do you think they should be assessed? (See Chapter 16 in your textbook.) almost ever 2 hrs The nurse documented vital signs at 1600, 1730, and 1830. Once the patient is discharged from the PACU, vital signs are often measured every 15 minutes for four times, every 30 minutes for four times, every hour for four times, and then every 4 hours for 24-48 hours if the patient’s condition is stable. Thereafter, if the patient is admitted, vital signs are assessed according to the facility’s policy, the patient’s condition, and the nurse’s judgment. Question 28 Not yet graded / 1 pts Still in the EPR, select Intake and Output from the Category drop-down menu. Exercise 3 - Question 3 Record Clarence Hughes’ intake and output for the past 3 days for the specified times. Sun 2300 Mon 0700 Mon 1500 Mon 2300 Tues 0700 Tues 1500 Tues 2300 Wed 0700 Sun 2300- I:899 O:830 Mon 0700: I:1364 O:1010 Mon 1500 I: O: Mon 2300 Tues 0700 Tues 1500 Tues 2300 Wed 0700 Sun 1500-2300 Intake: 899 Output: 830 Mon 0000-0700 Intake: 1364 Output: 1010 Mon 0700-1500 Intake: 1670 Output: 1750 Mon 1500-2300 Intake: 920 Output: 1100 Tues 2300-0700 Intake: 240 Output: 540 Tues 0700-1500 Intake: 1500 Output: 1050 Tues 1500-2300 Intake: 840 Output: 760 Wed 2300-0700 Intake: 240 Output: 420 Question 29 Not yet graded / 1 pts Exercise 3 - Question 4 Which is greater—Clarence Hughes’ intake or output? By how much? Is this expected? intake Intake is 7673; output 7460. Intake is greater than output by 213 mL. This is just about equal—insensible fluid loss is probably equal to or greater than the 213 mL. Question 30 Not yet graded / 1 pts Exercise 3 - Question 5 What are the possible consequences if this trend in fluid balance continues? None None. Fluid intake and output is balanced; patient should continue to recover without complications. Question 31 Not yet graded / 1 pts Click on Exit EPR. Click on Chart and then on 404. Click on Physician’s Orders. Exercise 3 - Question 6 Look at the physician’s postoperative orders written on Sunday at 1600. What is ordered to prevent postoperative atelectasis and/or pneumonia? Incentuve spirometer 10 times every hour while awake Incentive spirometer 10 times every hour while awake Question 32 1 / 1 pts Exercise 3 - Question 7 The physician prescribed enoxaparin. What is the purpose of this medication? Prevention of infection Prevention of deep vein thrombosis Pain management Reduction of postoperative constipation Question 33 1 / 1 pts Exercise 3 - Question 8 When preparing to administer enoxaparin, the review of which laboratory test result is most important? Calcium level Complete blood cell count Urinalysis Liver enzymes Question 34 1 / 1 pts Exercise 3 - Question 9 When reviewing Clarence Hughes' health history, which finding, if noted, would be cause for concern with the administration of enoxaparin? Renal impairment Immunodeficiency History of latex allergy Anemia Question 35 Not yet graded / 1 pts Exercise 3 - Question 10 What wound care is ordered on Sunday? dressing on knee Reinforce dressing to L knee as needed Question 36 Not yet graded / 1 pts Exercise 3 - Question 11 Explain how and when to perform the ordered wound care. Add more material to the existing dressing; completed when the dressing becomes wet from drainage. Question 37 Not yet graded / 1 pts Click on Return to Nurses' Station and then on 404. Inside Clarence Hughes' room, click on Take Vital Signs. Review these results. Click on Clinical Alerts. Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 0735: Empathy. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and then Nurse-Client Interactions to refresh the screen.) Exercise 3 - Question 12 What is Clarence Hughes’ major concern at this point? being stuffed up Constipation Question 38 Not yet graded / 1 pts Click on Medication Room. From the Medication Room, click on MAR to determine the medications that Clarence Hughes is ordered to receive at 0800 and any appropriate prn medications you may want to administer. (Note: You may click on Review MAR at any time to verify correct medication order. Click on the correct room number within the MAR. Remember to look at the patient name on the MAR to make sure you have the correct patient's record. Click on Return to Medication Room after reviewing the correct MAR.) Click on Unit Dosage. Click on drawer 404. From the list of available medications in the top window, select the medication(s) you would like to administer. After each medication you select, click on Put Medication on Tray. When you have finished putting your selected medications on the tray, click on Close Drawer. Click on View Medication Room. This time, click on Automated System. Your name and password will automatically appear. Click on Login. In box 1, select the correct patient; in box 2, choose the appropriate Automated System Drawer for this patent. Then click on Open Drawer. From the list of available medications, select the medication(s) you would like to administer. For each one selected, click on Put Medication on Tray. When you are finished, click on Close Drawer. Click on View Medication Room. From the Medication Room, click on Preparation and then highlight the medication you want to administer. Click on Prepare. Wait for the Preparation Wizard to appear; then provide any information requested. Click on Next, choose the correct patient to administer this medication to, and click on Finish. Repeat the previous three steps until you have prepared all the medications you want to administer. You can click on Review Your Medications and then on Return to Medication Room when you are ready. Once you are back in the Medication Room, you may go directly to Clarence Hughes’ room by clicking on 404 at bottom of screen. Administer the medication, utilizing the six rights of medication administration. After you have collected the appropriate assessment data and are ready for administration, click on Patient Careand then on Medication Administration. Verify that the correct patient and medication(s) appear in the left-hand window. Then click the down arrow next to Select. From the drop-down menu, select Administer and complete the Administration Wizard by providing any information requested. When the Wizard stops asking for information, click on Administer to Patient. Specify Yes when asked whether this administration should be recorded in the MAR. Finally, click on Finish. Now, let's see how you did! Click on Leave the Floor at the bottom of your screen. From the Floor Menu, click on Look at Your Preceptor's Evaluation and then click on Medication Scorecard. Exercise 3 - Question 13 Note below whether or not you correctly administered the appropriate medication(s). If not, why do you think you were incorrect? According to Table C in this scorecard, what resources should be used and what important assessments should be completed before administering the medication(s)? Did you utilize these resources and perform these assessments correctly? Medications that should have been administered are noted in the Medication Scorecard. The student should have assessed the patient’s allergies and name band before administering the medications. The patient’s chart should also have been assessed to check the expired MARs for the last time the milk of magnesia was administered because this is a prn drug. Bowel history should be assessed before administering docusate sodium and milk of magnesia. Lab work regarding coagulation should be assessed before administering the enoxaparin. No pain medicine should have been given because there are two strengths of oxycodone with acetaminophen available in the medication room and the strength for Clarence Hughes is not specified in the physician’s orders. Quiz Score: 7.25 out of 38 Submission Details: * Some questions not yet graded Time: Lesson 13 - Atrial Fibrillation Due No due date Points 31 Questions 31 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 217 minutes 3.86 out of 31 ** Some questions not yet graded Score for this quiz: 3.86 out of 31 * Submitted Aug 28 at 10:49am This attempt took 217 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 20 minutes to complete. Exercise 1 - Question 1 Describe the normal conduction system of the heart. The cardiac conduction system is a group of specialized cardiac muscle cells in the walls of the heart that send signals to the heart muscle causing it to contract. The main components of the cardiac conduction system are the SA node, AV node, bundle of His, bundle branches, and Purkinje fibers The conduction system begins with the sinoatrial (SA) node, located close to the surface of the right atrium near its junction with the superior vena cava. It is the heart’s primary pacemaker, with an intrinsic rate of 60 to 100 beats per minute (bpm). Impulses from the sinus node move directly through atrial muscle and lead to atrial depolarization, reflected in a P wave on the electrocardiogram (ECG). Atrial muscle contraction should follow. The impulse travels via slow and fast conduction pathways leading to the atrioventricular (AV) node, located just beneath the right atrial endocardium, between the tricuspid valve and the ostium of the coronary sinus. The impulse is delayed here before proceeding to the ventricles. This delay is reflected in the PR segment on the ECG. After the delay, the impulse travels into the bundle of His, down the right and left bundle branches and into the terminal Purkinje fibers. This leads to ventricular depolarization and contraction. Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 What is "atrial kick"? Why is this important? Active atrial contraction forces additional volumes of blood into the ventricles (often referred to as "atrial kick"). The atrial kick contributes a significant volume of blood toward ventricular preload (approximately 20%). Atrial kick, facilitated by a short delay in impulse conduction in the AV node, occurs when the atria contract before the ventricles. The atrial contraction contributes additional blood volume for a greater cardiac output. Question 3 0 / 1 pts Exercise 1 - Question 3 Identify the cardiac event represented by each of the waves and measured intervals: P wave: 0.08 -0.10 seconds PR interval: 0.12-0.20 QRS complex: 0.08-0.10 T wave: 0.10-0.25 U wave: QT interval: 0.4-0.44 1: 0.08 -0.10 seconds atrial depolarization 2: 0.12-0.20 the time required for atrial depolarization, as well as the impulse delay in the AV node, and the travel time to the Purkinje fibers 3: 0.08-0.10 ventricular depolarization 4: 0.10-0.25 ventricular repolarization 5: (You left this blank) slow repolarization of ventricular Purkinje fibers 6: 0.4-0.44 the total time required for ventricular depolarization and repolarization Question 4 Not yet graded / 1 pts Exercise 1 - Question 4 Identify and describe the eight steps of electrocardiogram (ECG) analysis. 1.evaluate the P wave -is it present -round and upright in Lead II -Precedes QRS complex -one P wave for every QRS 2.Evaluate atrial rhythm -regular -may have small variations caused by respirations -measure P-P intervals: from each P wave to the next 3.Determine the atrial rate 4.PR interval -count number of small squares between the beginning of P wave and the beginning of the QRS complex and multiply by 0.04 seconds 5.evaluate the ventricular rhythm 6.determine the ventricular rate 7. calculate the duration of the QRS complex -count number of small squares between the beginning and end of the QRS complex 8. calculate the duration of the QT interval -count number of squares from the beginning of the QRS complex to the end of the T wave -multiply by 0.04 seconds -normal range = 0.36-0.44 seconds Step 1: Determine the heart rate. Count the number of QRS complexes in 6 seconds and multiply by 10 Step 2: Determine the heart rhythm. By measuring the distance between P waves, and then again between R waves, the nurse can determine whether the patient’s atrial and ventricular rhythm is regular or irregular. A regular rhythm will have the same distance between all P waves and between all R waves. Step 3: Analyze the P waves. The nurse will check that the P wave shape is consistent throughout the strips, indicating that atrial depolarization is occurring from impulses originating from one focus, normally the SA node. The nurse will also determine whether there is a single P wave occurring before each QRS complex establishing that a relationship exists between each P wave and QRS complex. Step 4: Measure the PR interval. This is measured from the beginning of the P wave to the end of the PR segment. The normal PR interval should be 0.12-0.20 seconds and be constant throughout the strip. Step 5: Measure the QRS duration. This is measured from the beginning of the QRS complex to the J point, where the QRS complex ends and the ST segment begins. The normal QRS complex should be 0.04-0.10 seconds in width and all be similar in appearance throughout. Step 6: Examine the ST segment. The normal ST segment begins at the isoelectric line. ST elevation or depression is significant if displacement is 1 mm or more above or below the isoelectric line. Step 7: Assess the T wave. Note the shape and height of the T wave for peaking or inversion. Step 8: Measure the QT interval. A normal QT interval should be less than half the distance of the R-R interval. Question 5 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 35 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses’ Station. Click on 403 at the bottom of your screen. Read the Initial Observations. Exercise 2 - Question 1 What information regarding Piya Jordan’s cardiovascular status is obtained on initial observation? On 2 liter flow oxygen via nasal cannula with continuous oximetry. SpO2 95%. Abdominal dressing and binder in place, Jackson-Pratt drain with moderate amount serosanguinous drainage Atrial fibrillation is noted on telemetry monitor. Question 6 Not yet graded / 1 pts Exercise 2 - Question 2 What is telemetry monitoring? Telemetry is a way of monitoring your heart while you are in the hospital. It is used to: watch the pattern of your heartbeats. find any heart problems you may have with your heartbeat. see how well your medications are working. Telemetry monitoring is used for the ambulatory patient. The ECG cables are attached to a portable battery-operated transmitter held in a pouch worn by the patient. The ECG is transmitted via antennae located in strategic places, usually in the ceiling, to a remote monitor. Telemetry allows freedom of movement within a certain area without losing transmission of the ECG. Question 7 1 / 1 pts Exercise 2 - Question 3 During atrial fibrillation the atria depolarize in a disorganized manner at a rate of 350 to 600 times per minute. 1: 350 2: 600 Question 8 Not yet graded / 1 pts Exercise 2 - Question 4 Describe the rhythm strip you would expect to see on Piya Jordan’s monitor. No clear P waves; no atrial contractions; wavy baseline Question 9 Not yet graded / 1 pts Exercise 2 - Question 5 How does this differ from normal sinus rhythm (NSR)? Normal sinus rhythm is defined as the rhythm of a healthy heart. It means the electrical impulse from your sinus node is being properly transmitted. In adults, normal sinus rhythm usually accompanies a heart rate of 60 to 100 beats per minute. However, normal heart rates vary from person to person. Both atrial and ventricular rhythms are essentially regular (a slight variation in rhythm is normal). Atrial and ventricular rates are both 83 beats/min. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology, or shape. The PR interval measures 0.18 second and is constant; the QRS complex measures 0.06 second and is constant. Question 10 Not yet graded / 1 pts Click on Take Vital Signs. Exercise 2 - Question 6 Record Piya Jordan’s heart rate below and state whether the rhythm is controlled (ventricular rate less than 100) or uncontrolled (ventricular rate greater than 100) atrial fibrillation. Heart rate is 107 which is abouve the normal heart rate. Atrial fibrillation is an irregular and often rapid heart rate that occurs when the two upper chambers of your heart experience chaotic electrical signals. The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. s will vary according to the patient’s exact heart rate when vital signs are taken. If the heart rate was greater than 100 bpm, the patient would be in uncontrolled atrial fibrillation, meaning that the ventricular response is not controlled and is greater than a normal sinus rate. If the heart rate is less than 100, the patient is said to be in controlled atrial fibrillation. Question 11 0.29 / 1 pts Exercise 2 - Question 7 For what clinical manifestations consistent with atrial fibrillation should Piya Jordan be assessed for? Select all that apply. (Hint: See Chapter 34 in your textbook.) Fatigue Restlessness Lethargy Weakness Shortness of breath Dizziness Palpitations Hypertension Syncope Chest discomfort Question 12 Not yet graded / 1 pts Click on Patient Care and then on Physical Assessment. Complete a general assessment of Piya Jordan by clicking on the body system categories (yellow buttons) and subcategories (green buttons). Exercise 2 - Question 8 Does Piya Jordan present with any symptoms that are associated with atrial fibrillation? If not, how can you explain that? yes restlessness confusion dizziness Mild weakness in muscle strength is the only symptom identified. This weakness could also be attributed to the patient’s overall condition. The lack of clinical manifestations may be attributed to the chronic nature of Piya Jordan’s dysrhythmia, decreased activity level, and lack of coexisting cardiac disease. Question 13 Not yet graded / 1 pts Exercise 2 - Question 9 If Piya Jordan’s heart rate increases, how might the atrial fibrillation affect her blood pressure? Describe the underlying physiology. (Hint: Think about normal atrial kick.) A weakened blood vessel may rupture in or near the brain, or diseased arteries may become blocked by a clot or plaque buildup. Then there's atrial fibrillation. That's when stroke risk increases because the rapid heartbeat allows blood to pool in the heart, which can cause clots to form and travel to the brain. Piya Jordan would be at an increased risk for hypotension. Patients with atrial fibrillation lose their “atrial kick,” resulting in a decrease in cardiac output. As the heart rate increases, the heart has less time to fill with blood, increasing the risk for decreased cardiac output. Question 14 Not yet graded / 1 pts Click on Chart and then on 403. Click on Diagnostic Reports. Exercise 2 - Question 10 Did Piya Jordan have a 12-lead ECG done? If yes, what was the rhythm? If not, do you think it should have been done? Why or why not? no No, an ECG was not done. An ECG should have been done preoperatively for Piya Jordan based on her history of atrial fibrillation and her elevated digoxin level. Because of rising health care costs, however, physicians are sometimes reluctant to order tests that are not absolutely necessary. Despite this concern, the telemetry rhythm strip would give the physician the absolute necessary information regarding the patient's rhythm. Question 15 Not yet graded / 1 pts Exercise 2 - Question 11 For what potential complications related to atrial fibrillation should you monitor Piya Jordan? Describe appropriate nursing assessments related to each complication. (Hint: See Chapter 34 in your textbook.) stroke heart attack, blood clots Pulmonary embolism; assess for shortness of breath, chest pain, hemoptysis (blood-tinged sputum), cough, apprehension, restlessness, and a feeling of impending doom. Systemic emboli, particularly an embolic stroke; assess for manifestations of stroke, such as changes in mentation or level of consciousness, speech, sensory function, and motor function. Question 16 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Piya Jordan (Room 403). Click on Go to Nurses’ Station Click on MAR and then on tab 403. Exercise 3 - Question 1 What medication is prescribed to treat Piya Jordan’s atrial fibrillation? Describe the pharmacodynamics of this medication as related to atrial fibrillation. (Hint: You may need to consult the Drug Guide.) Beta blockers and calcium channel blockers Digoxin; decreases conduction between the sinoatrial node and atrioventricular node, thus decreasing the ventricular response rate. The positive inotropic effect of digoxin also helps to increase the cardiac output that is decreased with atrial fibrillation related to the loss of the atrial kick. Question 17 Not yet graded / 1 pts Exercise 3 - Question 2 Why did the physician order a digoxin level when the patient first presented to the emergency department? (Hint: Review the patient's presenting symptoms as well as the Drug Guide.) Digoxin remains one of the most frequently prescribed drugs in the management of atrial fibrillation. The main indications for digoxin in atrial fibrillation are restoration of sinus rhythm, prevention of recurrence and slowing of the ventricular rate. The patient’s presenting symptoms of nausea and vomiting can also be signs of digoxin toxicity. Question 18 1 / 1 pts Click on Return to Nurses' Station. Click on Chart and then on 403. Click on Laboratory Reports. Exercise 3 - Question 3 Piya Jordan’s digoxin level in the Emergency Department was __________ ng/mL. 2.1 s 2.1 Question 19 1 / 1 pts Exercise 3 - Question 4 The digoxin level you recorded in question 3 is considered: subtherapeutic therapeutic toxic. Question 20 0.57 / 1 pts Exercise 3 - Question 5 For what symptoms of digoxin toxicity would you monitor Piya Jordan? Select all that apply. Tachycardia Visual disturbances Headache Nausea Constipation Anorexia Fatigue Labile emotions Facial pain Personality changes Question 21 0 / 1 pts Exercise 3 - Question 6 Piya Jordan’s potassium level in the Emergency Department was ____________ mEq/L. 20 s 3.3 Question 22 Not yet graded / 1 pts Exercise 3 - Question 7 How does this relate to possible digoxin toxicity? (Hint: See Chapter 11 in your textbook.) Some early warning signs of overdose are confusion, loss of appetite, nausea, vomiting, diarrhea, or vision problems. Other signs of overdose are changes in the rate or rhythm of the heartbeat (becoming irregular or slow), palpitations (feeling of pounding in the chest), or fainting. Hypokalemia increases the risk of digoxin toxicity. Patients with hypokalemia may display digoxin toxicity manifestations even when serum level is WNL. Question 23 Not yet graded / 1 pts Click on History and Physical. Exercise 3 - Question 8 What other medication was Piya Jordan prescribed related to atrial fibrillation before this admission? Explain the rationale for this medication. (Hint: Think of potential serious complications of atrial fibrillation.) Home medications include Digoxin 0.125 mg daily, Warfarin 5 mg daily, Celecoxib 200 mg every 12 hours. Warfarin 5 mg daily. This is an anticoagulant prescribed for patients with sustained atrial fibrillation to prevent the formation of blood clots in the atrium and therefore decrease the risk for embolic complications related to this dysrhythmia. Question 24 Not yet graded / 1 pts Click on Physician's Orders. Exercise 3 - Question 9 What two items did the physician prescribe preoperatively to reverse Piya Jordan’s anticoagulation? How would you know whether they were effective? Explain. including: heparin. warfarin (Coumadin) rivaroxaban (Xarelto) (1) Phytonadione 10 mg subcutaneous injection upon arrival to unit (2) 1 unit fresh frozen plasma (FFP) on call to operating room The phytonadione is vitamin K—the antidote for warfarin. This will reverse the anticoagulant effect of warfarin. Fresh frozen plasma contains clotting factors that will increase the coagulability of Piya Jordan’s blood during surgery. The effectiveness of these interventions can be evaluated by assessing the patient's PT/INR lab values—the nurse would know the medications were effective when the PT/INR values decrease below the therapeutic levels (INR less than 2.0). Question 25 Not yet graded / 1 pts Exercise 3 - Question 10 What medication was ordered postoperatively on Wednesday at 0730 to prevent clot formation? coumadin Enoxaparin 40 mg subcutaneously every 12 hours Question 26 Not yet graded / 1 pts Click on Nursing Admission. Exercise 3 - Question 11 What knowledge (or lack of knowledge) does Piya Jordan verbalize regarding her history of atrial fibrillation? (Hint: Look at the Health Promotion section.) Piya Jordan demonstrates a lack of understanding of atrial fibrillation when she states, “My doctor says I have atrial fibrillation. Maybe I just have the flu.” Question 27 Not yet graded / 1 pts Click on Patient Education. Exercise 3 - Question 12 What might you add to these outcomes based on your to question 11? she will have a more better heart rhythm Patient/family will verbalize understanding of atrial fibrillation and related medications. Question 28 Not yet graded / 1 pts Exercise 3 - Question 13 What surgical treatment options may be used for patients with recurrent or sustained atrial fibrillation? Radiofrequency catheter ablation, implantation of pacemaker and/or atrial defibrillator, and/or the maze procedure Question 29 0 / 1 pts Click on Return to Nurses’ Station. Click on Medication Room. Click on MAR to determine medications that Piya Jordan is ordered to receive at 0800. (Note: You may click on Review MAR at any time to verify correct medication order. You must click on the room number tab within the MAR. Remember to look at the patient name on the MAR to make sure you have the correct patient's record. Click on Return to Medication Room after reviewing the correct MAR.) Based on your care for Piya Jordan, access the various storage areas of the Medication Room to obtain the necessary medications you need to administer. For each area you access, first select the medication you plan to administer and then click on Put Medication on Tray. When finished with a storage area, click on Close Drawer. Click on View Medication Room. Click on Preparation and choose the correct medication to administer. Click on Prepare. Wait for the Preparation Wizard to appear; then provide any information requested. Click on Next and choose the correct patient to administer the medication to. Click on Finish. Repeat the above three steps until all medications that you want to administer are prepared. You can click on Review your Medications and then on Return to Medication Room when you are ready. Once you are back in the Medication Room, you may go directly to Piya Jordan’s room by clicking on 403 at the bottom of the screen. Administer the medication, utilizing the six rights of medication administration. After you have collected the appropriate assessment data and are ready for administration, click on Patient Careand then on Medication Administration. Verify that the correct patient and medication(s) appear in the left-hand window. Then click the down arrow next to Select. From the drop-down menu, select Administer and complete the Administration Wizard by providing any information requested. When the Wizard stops asking for information, click on Administer to Patient. Specify Yes when asked whether this administration should be recorded in the MAR. Finally, click on Finish. Exercise 3 - Question 14 You should administer the IV digoxin over ___________ minutes. 30 s 5 Question 30 Not yet graded / 1 pts Exercise 3 - Question 15 What should you have assessed before administering digoxin to Piya Jordan today? her vitals Digoxin level drawn this morning Pulse Any signs/symptoms of digoxin toxicity Question 31 Not yet graded / 1 pts Now let's see how you did! Click on Leave the Floor at the bottom of your screen. From the Floor Menu, click on Look at Your Preceptor's Evaluation. Click on Medication Scorecard. Exercise 3 - Question 16 Note below whether or not you correctly administered the appropriate medication(s). If not, why do you think you were incorrect? According to Table C in this scorecard, what resources should be used and what important assessments should be completed before administering the medication(s)? Did you utilize these resources and perform these assessments correctly? yes Medications that should have been administered are noted in the Medication Scorecard. The student should have assessed the patient’s allergies and name band before administering the medications. The cefotetan should not have been administered because the patient is allergic to cephalosporins. In addition to assessments noted in question 14, respiratory status should be assessed before and during administration of morphine sulfate. Piya Jordan’s most recent potassium level should be assessed before administering the potassium chloride. There were two dosage strengths of morphine sulfate available in the Medication Room. The student would need to make sure the correct dosage strength was selected. Dosage calculation was also required to administer the correct dose of digoxin as it was available with 0.25 mg/mL and the order was for 0.125 mg. Lesson 12 - Pulmonary Embolism Due No due date Points 29 Questions 29 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 191 minutes 0.8 out of 29 ** Some questions not yet graded Score for this quiz: 0.8 out of 29 * Submitted Sep 2 at 11:31am This attempt took 191 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 5 minutes to complete. Exercise 1 - Question 1 Briefly describe the pathophysiology of pulmonary embolism. Pulmonary embolism often arise from thrombi originating in the deep venous system of the lower extremities or pelvis. A blood clot dislodges and is swept into the pulmonary circulation and lodges in a pulmonary artery. A pulmonary embolism (PE) is a collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary blood flow, leading to reduced oxygenation of the whole body, pulmonary tissue hypoxia, and potential death. Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 Identify the most common source of pulmonary emboli. The most common cause of such a blockage is a blood clot that forms in a deep vein in the leg and travels to the lungs, where it gets lodged in a smaller lung artery. Most often occurs when a blood clot from a venous thromboembolism (VTE), especially a deep vein thrombosis (DVT) in a vein in the legs or the pelvis, breaks off and travels through the vena cava into the right side of the heart. Question 3 0.8 / 1 pts Exercise 1 - Question 3 Which are factors for the development of a pulmonary embolism? Select all that apply. Advanced age Heredity Obesity Immobility Recent surgery Central venous catheters Question 4 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 2. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click on Get Report. Click on Go to Nurses’ Station. Click on 404 at the bottom of your screen. Exercise 2 - Question 1 What is your initial observation as you enter the patient’s room? Anxious and requesting help for chest pain and shortness of breath. Alert and oriented. Tachypneic. Color slightly ashen. Diaphoretic Patient is sitting up, leaning forward with hands on chest. Patient is complaining of chest pain and shortness of breath. Color ashen. Tachypneic, diaphoretic. Family worried. Question 5 Not yet graded / 1 pts Exercise 2 - Question 2 What should your priority actions be at this point? perform a vital assessment focused on chest pain. provide oxygen mask Assess patient by checking vital signs and auscultating heart and lung sounds. Apply oxygen. Call provider. Question 6 Not yet graded / 1 pts Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 1115: Interventions—Airway. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and then on Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 3 Review the nurse's actions. Was it appropriate for her to leave Clarence Hughes to get the oxygen? Why or why not? If not, what else could she have done? No she should've called for assistance and not leave the patient unattended. No, the nurse should not have left the patient’s bedside because the patient was in acute respiratory distress and was at risk for cardiopulmonary arrest. The nurse should have called for help and stayed with the patient and the family. Once the oxygen was applied, the nurse should have completed a focused assessment and called the provider, not waited until the patient was feeling a little better. This is an acute, emergency situation that requires critical thinking and fast action. Question 7 Not yet graded / 1 pts Exercise 2 - Question 4 What classic signs and symptoms of pulmonary embolism is Clarence Hughes displaying? diaphoretic chest pain tachycardia tachypnea Sudden onset of dyspnea Chest pain Apprehension, restlessness Feeling of impending doom Tachypnea Question 8 Not yet graded / 1 pts Exercise 2 - Question 5 Suspecting a pulmonary embolus, for what other clinical manifestations would you assess Clarence Hughes? (Hint: See Chapter 32 in your textbook.) pain Cough, hemoptysis, crackles, pleural friction rub, tachycardia, S3 or S4 heart sound, diaphoresis, lowgrade fever, petechiae over chest and axillae, decreased arterial oxygenation saturation. The nurse should also assess for cardiac manifestations, such as distended neck veins, syncope, cyanosis and hypotension. It is important to remember that many patients with Pulmonary Embolism do not have classic symptoms. Question 9 Not yet graded / 1 pts Click on Chart and then on 404 for Clarence Hughes' chart. Click on History and Physical. Exercise 2 - Question 6 Based on the patient’s history and current reason for hospitalization, what risk factors for deep vein thrombosis (DVT) and resultant pulmonary embolism does Clarence Hughes have? degenerative joint disease and osteoarthritis chronic pain in left knee Smoker for 40 years Immobility Orthopedic surgery Question 10 Not yet graded / 1 pts Click on Physician's Orders. Exercise 2 - Question 7 Look at the orders dated Wednesday at 1120. Document these orders below and provide a rationale for each order. STAT labs: D-dimer, PT/INR/PTT, CBC, and ABGs. STAT chest x-ray STAT spiral CT STAT ventilation-perfusion scan Start cardiac telemetry monitoring. Monitor vital signs every 30 minutes. Start oxygen 6 L/min via face mask immediately. Titrate to keep oxygen saturation levels above 94%. Stop CPM. Start oxygen 6 L/min via face mask immediately; titrate to keep oxygen saturation levels above 94%: To supplement oxygenation Arterial blood gas STAT: To determine patient's oxygenation status Chest x-ray STAT: To identify any pulmonary abnormalities that may be causing patient’s condition Ventilation perfusion scan STAT: To identify probability of pulmonary embolus Venous Doppler study: To identify DVT as cause of pulmonary embolus Monitor vital signs every 30 minutes: To monitor for worsening of patient’s condition and complications of pulmonary embolus Oxygen 3 L flow by nasal cannula: To increase oxygenation status of patient Stop CPM: To prevent more of a DVT from being dislodged Question 11 Not yet graded / 1 pts Click on Return to Room 404. Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 1135: Change in Patient Condition. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and then on Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 8 As the nurse is explaining care to the family, she states that a transporter will be coming to take Clarence Hughes for a ventilation-perfusion scan. Would you send this patient down to radiology with just the transporter? Why or why not? no in case of a emergency he will need a nurse there with him to ensure his safety. No, this patient should be accompanied by a nurse while being transported off the floor for testing. He is at risk for decreased cardiac output and impaired gas exchange related to a possible pulmonary embolus. Both of these conditions could result in a rapid deterioration of his health status and the need for a quick response from the health care team. Question 12 Not yet graded / 1 pts Exercise 3 - Virtual Hospital Activity This exercise will take approximately 30 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 3. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Clarence Hughes (Room 404). Click on Go to Nurses' Station. Click on Chart and then on 404 for Clarence Hughes' chart. Select and review the Laboratory Reports and Diagnostic Reports. Exercise 3 - Question 1 Below, document the results of the ordered diagnostic and laboratory testing. Please note that the laboratory results are reported for Wednesday at 1130. chest xray Ventilation perfusion scan Computed Tomography PULMONARY ANGIOGRAM (CTPA) WITH CONTRAST Arterial blood gas: Respiratory alkalosis secondary to hyperventilation; pH 7.46, PaO2 76, bicarb 22, PaCO2 33, O2 sat 93% Chest x-ray: Normal chest x-ray Ventilation-perfusion scan: High probability of mild pulmonary embolus in middle lobe right lung Venous Doppler study: Partial venous occlusion with thrombosis in left popliteal vein Question 13 Not yet graded / 1 pts Exercise 3 - Question 2 Based on the above results, what would you conclude to be the cause of Clarence Hughes' acute respiratory distress? He is having a hard time trying to maintain it Pulmonary embolus originating from DVT of operative leg Question 14 Not yet graded / 1 pts Click on Physician's Orders. Exercise 3 - Question 3 What orders were written to treat Clarence Hughes’ pulmonary embolism? Heparin, Warfarin Strict bed rest Vital signs every 4 hours Heparin bolus and continuous infusion with titration orders based on lab results Question 15 Not yet graded / 1 pts Exercise 3 - Question 4 What laboratory test will be used to titrate the heparin infusion? What are the normal values for this test? Several tests are available to monitor UFH therapy including whole blood clotting time, aPTT, activated clotting time, anti–factor Xa activity, and plasma heparin concentrations . a heparin level of 0.2 to 0.4 IU/mL PTT; normal values vary (20 to 30 seconds in some laboratories and 30 to 40 seconds in others) Question 16 Not yet graded / 1 pts Exercise 3 - Question 5 What is the desired therapeutic level for this laboratory test? 1.5 to 2.5 times normal Question 17 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on MAR and then on 404 for Clarence Hughes' record. Exercise 3 - Question 6 How many mL of heparin would you administer for the bolus dose if the medication on hand is Heparin 5000 units/1 mL? Heparin 25,000 units in 250 mL NS 18 units/kg/hr IV continuously Using sliding scale per a PTT. Admit wt-94.1 kg Bolus dose = 80 units/kg = 80 x 94.1 kg = 7528 units 5000 units/1 mL on hand 7528 units/5000 units = 1.5 mL Question 18 Not yet graded / 1 pts Exercise 3 - Question 7 If you were the nurse starting the heparin infusion, at what rate would you set the IV pump to infuse this medication? The order is for 18 units/kg/hr. The patient’s weight is 94.1 kg. 18 units/kg/hr X 94.1 kg = 1693.8 units/hr. The heparin IV dilution is 25,000 units in 250 mL NS. (1693.8 units/hr divided by 25,000) X 250 mL = 16.938 mL/hour. Depending on the type of IV pump used, the patient would receive either 16.9 or 17 mL/hr. Question 19 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on Chart and then on 404 for Clarence Hughes' record. Click on Laboratory Reports. Exercise 3 - Question 8 What were the results of the PTT and INR at 1300 today? Why were these tests ordered prior to starting the heparin? INR 1.07 PTT 27 The PTT was 27 and the INR was 1.07. The PTT was drawn as a baseline to establish therapeutic response to the heparin infusion. The INR will serve as a baseline when the patient changes over to warfarin (Coumadin). Question 20 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on 404 to enter Clarence Hughes' room. Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 1510: Disease Management. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and then on Nurse-Client Interactions to refresh the screen.) Exercise 3 - Question 9 When the patient's son asks the nurse whether the pulmonary embolism would delay his father’s discharge, the nurse states that the heparin takes 2 days to stabilize. Does this mean that the patient will be discharged on heparin? If not, what medication will be used to minimize clot formation? Explain why the patient is not started on this medication rather than heparin. Heparin therapy usually continues for 5 to 10 days. Most patients are started on an oral anticoagulant, such as warfarin (Coumadin), on the first or second day of heparin use. Therapy with both heparin and warfarin continues until the patient has an INR of 2.0 to 3.0, which typically takes 48 to 72 hours to achieve. To facilitate early discharge, a low-molecular-weight heparin may be used along with the warfarin. Heparin is usually infused for 5 days and continues for 24 hours after the INR is 2.0 Question 21 Not yet graded / 1 pts Exercise 3 - Question 10 What lab test(s) will be used to monitor the therapeutic effect of warfarin (Coumadin)? What is the therapeutic range for these tests? PT and INR PT and INR. The PT should be 1.5 to 2.0 times the control. The INR should be 2.5 to 3.0 or 3.0 to 4.5 for recurrent PE. Question 22 Not yet graded / 1 pts Exercise 3 - Question 11 For what possible complications would you monitor Clarence Hughes related to the pulmonary embolism? Recurrence. Cardiac arrest. Pleural effusion. Pulmonary infarction. Arrhythmia. Pulmonary hypertension. Abnormal bleeding. Embolectomy complications Increased pulmonary pressures and decreased cardiac output can lead to heart failure and even cardiogenic shock. Impaired gas exchange can lead to hypoxemia and acute respiratory failure. The patient is also at risk for bleeding secondary to anticoagulant and/or fibrinolytic therapy. Question 23 Not yet graded / 1 pts Exercise 4 - Virtual Hospital Activity This exercise will take approximately 20 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 4. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) Click on Chart and then on 404 for Clarence Hughes' chart. (Remember: You are not able to visit patients or administer medications during Period of Care 4. You are able to review patient records only.) Click on Laboratory Reports. Exercise 4 - Question 1 What is the PTT result for 1900? PTT 63 63 Question 24 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on MAR and then on 404 for Clarence Hughes' record. Click on Physician's Orders. Exercise 4 - Question 2 What would you do now with the heparin infusion? Calculate the correct infusion rate and document below. Heparin bolus 80 units/kg IV x1 now. Immediately follow Heparin bolus with Heparin infusion to run at 18 units/kg/hour. Give a heparin bolus of 40 units/kg and increase the IV heparin by 2 units/kg/hr. The nurse would give Clarence Hughes a bolus of 3764 units of heparin (based on the patient’s weight of 94.1 kg) and increase the heparin IV infusion rate by 188.2 units/hr so that the patient will be receiving 1882 units/hr (188.2 added to the present 1693.8 units/hr). Because the heparin was originally infusing at 18 units/kg/hr, the nurse will increase this to 20 units/kg/hr. This can be calculated as follows: The patient’s weight is 94.1 kg. 20 units/kg/hr X 94.1 kg = 1882 units/hr. The heparin IV dilution is 25,000 units in 250 mL NS. (1882 units/hr divided by 25,000) X 250 mL = 18.82 mL/hr. Depending on the type of IV pump used, the patient would receive either 18.8 or 19 mL/hr. Question 25 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on Kardex and then on 404 for Clarence Hughes' record. Exercise 4 - Question 3 Are there any additional outcomes that should be added based on the patient’s current setback? If so, list these outcomes. no Yes, the nurse should add the following outcomes related to patient's risk for decreased cardiac output: Patient will maintain pulse rate and blood pressure within the normal ranges. Patient will maintain a urine output of at least 30 mL/hr. Patient will demonstrate an absence of cyanosis. Question 26 Not yet graded / 1 pts Exercise 4 - Question 4 If the heparin is not effective in treating Clarence Hughes and his condition worsens, what other pharmacologic treatment might be helpful? Explain. levonox Fibrinolytic drugs such as streptokinase can be used to actually dissolve the blood clot in the pulmonary vasculature and revascularize the area of infarction. Question 27 Not yet graded / 1 pts Exercise 4 - Question 5 Describe appropriate nursing interventions to prevent injury for Clarence Hughes while he is receiving anticoagulant and/or fibrinolytic therapy. Monitor for signs of bleeding, and instruct your patients to immediately report any of the following indications to their heath care providers: dark brown or red urine, tarry stools, large ecchymoses, epistaxis, excessive menstrual flow, prolonged bleeding from cut or injury, and bleeding gums. Handle patient gently. Use a lift sheet when moving and repositioning the patient in bed. Avoid venipunctures and intramuscular (IM) injections. When injections or venipunctures are necessary, use smallest gauge needle possible. Hold pressure on any venipuncture or needlestick site for at least 5 minutes. Apply ice to areas of trauma. Test all urine, vomitus, and stool for the presence of occult blood. Observe IV sites every 4 hours for bleeding. Instruct patient to notify nursing personnel immediately if any trauma occurs and if bleeding or bruising is noticed. Avoid trauma to rectal area—no rectal temperatures or enemas; use well-lubricated suppositories with caution. Measure abdominal girth every 8 hours. Use an electric shaver rather than a razor. Use a soft-bristled toothbrush, do not use floss, and check to make certain that dentures fit and do not rub. Encourage patient not to blow nose or stick objects into nose. Instruct patient to wear shoes with firm soles whenever the patient is ambulating. Ensure that antidotes to anticoagulation therapy are on the unit. Monitor laboratory values daily (CBC, platelet count, aPTT, PT, INR). Question 28 Not yet graded / 1 pts Exercise 4 - Question 6 If Clarence Hughes’ condition deteriorates, what surgical treatment might be needed? Explain. Percutaneous Thrombolysis and Embolectomy A surgical embolectomy would be needed. This is an invasive procedure using the cardiopulmonary bypass machine to enable the surgeon to enter the pulmonary vasculature and actually remove the embolus. Question 29 Not yet graded / 1 pts Exercise 4 - Question 7 If this patient develops another pulmonary embolus, what further treatment might the physician consider to prevent the problem from recurring in the future? Explain. Blood Thinners. Doctors call these “anticoagulants.” They keep your blood from forming clots Compression Stockings Exercise Stretching During Trips Lifestyle Changes. An inferior vena caval interruption procedure would be performed to prevent blood clots in the legs from reaching the pulmonary vasculature. This procedure involves placing a filter (i.e., "bird’s nest" or "umbrella") percutaneously into the inferior vena cava. This filter traps the clots while still allowing blood flow up the vein. Lesson 11 - Emphysema and Pneumonia Due No due date Points 31 Questions 31 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 277 minutes 4 out of 31 ** Some questions not yet graded Score for this quiz: 4 out of 31 * Submitted Sep 3 at 11:46am This attempt took 277 minutes. Question 1 Not yet graded / 1 pts Exercise 1 - Writing Activity This exercise will take approximately 20 minutes to complete. Exercise 1 - Question 1 To which categories of lung disease does emphysema belong? Along with asthma and chronic bronchitis, emphysema belongs to a group of lung diseases known as chronic obstructive pulmonary disease (COPD). Chronic airflow limitation (CAL) Chronic obstructive pulmonary disease (COPD) Question 2 Not yet graded / 1 pts Exercise 1 - Question 2 Briefly describe the pathophysiology of emphysema. the air sacs in the lungs (alveoli) are damaged. Over time, the inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream. Protease enzymes, normally present to destroy and eliminate particles and organisms inhaled during breathing, are present in higher-than-normal levels. They damage the alveoli and small airways by breaking down elastin. The alveolar sacs lose their elasticity and the small airways collapse or narrow. Some alveoli are destroyed and others become large and flabby with decreased area for effective gas exchange. An increased amount of air becomes trapped in the lungs, caused by loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into air-filled spaces called bullae, and collapse of small airways (bronchioles). These changes greatly increase the work of breathing. The hyperinflated lung flattens the diaphragm, weakening the effect of the muscle. Hence the patient must use accessory muscles (neck, chest wall, and abdomen) to breath. The increased effort increases oxygen demand, making the patient work harder and resulting in an "air hunger" sensation. Gas exchange is also affected by the increased work of breathing and loss of alveolar tissue. Question 3 Not yet graded / 1 pts Exercise 1 - Question 3 Briefly describe the pathophysiology of pneumonia. Most pneumonia occurs when a breakdown in your body's natural defenses allows germs to invade and multiply within your lungs. To destroy the attacking organisms, white blood cells rapidly accumulate. Along with bacteria and fungi, they fill the air sacs within your lungs (alveoli). Pneumonia is an excess of fluid in the lungs resulting from an inflammatory process. The inflammation occurs in the interstitial spaces, the alveoli, and often the bronchioles. The process of pneumonia begins when organisms penetrate the airway mucosa and multiply in the alveolar spaces. White blood cells migrate to the area of infection, causing local capillary leak, edema, and exudate. These fluids collect in and around the alveoli and the alveolar walls thicken. RBCs and fibrin move into the alveoli. The capillary leak spreads the infection to other areas of the lung. The fibrin and edema of inflammation stiffen the lung, causing decreased lung compliance and a decline in the vital capacity. Alveolar collapse (atelectasis) further reduces the ability of the lungs to oxygenate the blood moving through it. As a result, arterial oxygen level fall, causing hypoxemia. Question 4 1 / 1 pts Exercise 1 - Question 4 Which are risk factors for community-acquired pneumonia? Select all that apply. Older adult History of chronic lung disease Uses tobacco products Uses alcohol Poor nutritional status Recent exposure to influenza infection Has not received pneumococcal vaccination in the past 5 years Question 5 1 / 1 pts Exercise 1 - Question 5 When caring for a patient with pneumonia, empyema may result. What does this entail? The lung collapses. There is a solidification in one of the lung's lobes. Bacteria has infiltrated the blood stream. There is a collection of pus in the pleural cavity. Question 6 1 / 1 pts Exercise 1 - Question 6 Which is the most common cause of bacterial pneumonia? Staphylococcus Streptococcus Pneumococcus Meningococcus Question 7 Not yet graded / 1 pts Exercise 2 - Virtual Hospital Activity This exercise will take approximately 45 minutes to complete. Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are already in the virtual hospital from a previous exercise, click on Leave the Floor and then on Restart the Program to get to the sign-in window.) From the Patient List, select Patricia Newman (Room 406). Click on Get Report. Exercise 2 - Question 1 What questions would you ask the outgoing nurses to obtain needed information that was not identified in the report? when did she start feeling this way? has she been smoking today? When did Patricia Newman’s symptoms begin? Does she complain of pain on inspiration? Were antibiotics started? What is the patient's mentation? Does she smoke cigarettes? Does she have any respiratory history? What were her previous arterial blood gas (ABG) results? Has she received any medications for her increased temperature? Question 8 1 / 1 pts Exercise 2 - Question 2 Match the clinical manifestations identified in the report with the pathophysiologic basis of each manifestation. (A) Release of pyrogens by phagocytes which triggers hypothalamus (B) Fluid from pulmonary capillaries and RBCs invades alveoli (C) Fluid accumulation triggers receptors in trachea, bronchi, and bronchioles (D) Increased work of breathing, pain, and anxiety Dyspnea D Fever A Cough C Yellow sputum B Question 9 Not yet graded / 1 pts Click on Go to Nurses’ Station. Click on Chart and then on 406. Click on History and Physical. Exercise 2 - Question 3 What risk factors for community-acquired pneumonia does Patricia Newman have? smoker, alcoholic, emphysema for 12 years. pneumonia, being elderly Older adult Chronic condition (emphysema) Cigarette smoking Question 10 Not yet graded / 1 pts Click on Nursing Admission. Exercise 2 - Question 4 What other risk factor for community-acquired pneumonia is documented on this form? No,being in and out hospital No history of pneumococcal or flu vaccination Question 11 Not yet graded / 1 pts Click on Return to Nurses’ Station. Click on 406 at the bottom of your screen. Read the Initial Observations. Click on Take Vital Signs. Exercise 2 - Question 5 What should be your priority nursing assessment/intervention(s) based on your initial observation of Patricia Newman? Take vital signs Take vital signs Auscultate lung sounds Apply oxygen via nasal cannula at 2 L Explain to patient the necessity for keeping oxygen on Identify whether patient has medication ordered for fever; if so, assess time of last dose and administer as soon as possible Question 12 Not yet graded / 1 pts Click on Patient Care and then on Physical Assessment. Exercise 2 - Question 6 Perform a focused assessment based on her admitting diagnosis by clicking on the body categories (yellow buttons) and subcategories (green buttons). Record your assessment findings, focusing on the assessment areas listed below. How has Patricia Newman’s condition changed since report? Respiratory Cardiovascular Mental Status Respiratory: Labored and shallow respiratory effort. Patient removes nasal cannula for assessment against RN advice. Bilateral breath sounds with coarse crackles auscultated throughout lung fields. Aeration mildly decreased. Productive cough of thick yellow sputum. Employing some accessory muscles. Tachypnea. Exertional dyspnea. Oxygen saturation of 90% in 2 liter flow oxygen via nasal cannula. Cardiovascular:Apical rate and rhythm regular and even. Sinus tachycardia. S1 and S2 auscultated. No murmurs, clicks, or rubs. No jugular vein distention. Mental Status: Alert and oriented to person, place, time, and situation. Speech, perceptual ability, and cognition age appropriate. Mild anxiety level with labored respiratory effort. Respiratory Assessment findings: Labored and shallow respiratory effort. Removes oxygen cannula against nurse's advice. Lungs with coarse crackles throughout. Change in assessment: No accessory muscle use noted on second assessment. Crackles are a new assessment finding—not noted in report. Cardiovascular Assessment findings: Sinus tachycardia. Apical rate regular and even; no clicks, rubs, or murmurs. No jugular vein distention (JVD). Change in assessment: No change. Mental Status Assessment findings: Mild anxiety level. Awake, alert, and oriented. Speech clear and appropriate. Change in assessment: No data available from report. Question 13 Not yet graded / 1 pts Click on Patient Care and then on Nurse-Client Interactions. Select and view the video titled 0730: Prioritizing Interventions. (Note: Check the virtual clock to see whether enough time has elapsed. You can use the fast-forward feature to advance the time by 2-minute intervals if the video is not yet available. Then click again on Patient Care and on Nurse-Client Interactions to refresh the screen.) Exercise 2 - Question 7 Evaluate the nurse’s actions based on the patient’s current status. How does this nurse’s action differ from the plan of care you outlined in question 5 of this exercise? This will vary depending on what the student ed for question 5, but the student should note that the nurse prioritized putting the oxygen back on the patient. The nurse stated that she was going to get some medication for the fever; it can be assumed that she identified the time of the last dose and that Patricia Newman was able to have the medication at the present time. The nurse in the video did not perform a respiratory assessment on Patricia Newman or take other vital signs, although it may be assumed that because the nurse knew the patient's temperature, the vital signs may already have been taken. Additionally, although the nurse noted the reason for applying the oxygen, she did not emphasize to the patient the necessity of not removing it again. Question 14 Not yet graded / 1 pts Exercise 2 - Question 8 What nursing interventions might be done to alleviate the patient’s anxiety? provide a calm and peaceful enviorment, and encourage exercises Patient teaching regarding the use of oxygen and other treatment plans such as medication would help decrease patient anxiety by giving the patient hope for improvement in her condition. A cool environment might help to alleviate anxiety related to discomfort from fever and dyspnea. Pursed-lip breathing can minimize air trapping in a patient with emphysema, thus improving oxygenation and alleviating anxiety related to hypoxemia. Provide a calm unhurried environment. Demonstrate patience and use active listening techniques. Question 15 Not yet graded / 1 pts Click on Chart and then on 406 for Patricia Newman’s chart. Click on Laboratory Reports. Exercise 2 - Question 9 Identify any abnormal laboratory results and describe how they correlate with Patricia Newman’s diagnosis of pneumonia. The patients wbc is low The patient’s white blood cell count (WBC) is elevated at 16,000, indicating the presence of an infectious process. The patient’s PaO2 is also low, which correlates with both the pneumonia and the patient’s history of emphysema. Question 16 Not yet graded / 1 pts Click on Return to Room 406. Click on Drug Guide in the lower left-hand corner to access the Drug Guide. Exercise 2 - Question 10 What is the desired therapeutic effect of ipratropium bromide? How could the nurse assess whether the desired effect was achieved? Ipratropium bromide, sold under the trade name Atrovent among others, is a medication which opens up the medium and large airways in the lungs. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is used by inhaler or nebulizer. Ipratropium is an anticholinergic drug that should cause bronchodilation and improve the patient’s oxygenation status. The nurse would assess the patient's respiratory rate and rhythm, lung sounds, level of consciousness (LOC), peak expiratory flow (PEF), and skin color to determine effectiveness of the drug. Question 17 Not yet graded / 1 pts Exercise 2 - Question 11 What is the desired therapeutic effect of cefotetan? How could the nurse assess whether the desired effect was achieved? negative C&S Cefotetan is an antibiotic used to treat the bacterial infection causing Patricia Newman’s pneumonia. The nurse would assess for a decrease in the patient’s WBC, a return of her body temperature to normal and resolution of respiratory difficulties to determine the effectiveness of the drug. Also, a change in the color of sputum from yellow to clear or white would signify resolution of the infection. Question 18 Not yet graded / 1 pts Exercise 2 - Question 12 What is the rationale for administration of IV fluids related to pneumonia? so the patient will remain hydrated To provide hydration to liquefy the secretions and enable expectoration. Hydration will also replace insensible fluid loss associated with hyperthermia related to Patricia Newman's fever. Question 19 Not yet graded / 1 pts Click on Return to Room 406. Click on Medication Room. Click on MAR to determine medications that Patricia Newman is ordered to receive at 0800 and any prn medications you may want to administer. (Note: You may click on Review MAR at any time to verify correct medication order. You must click on the correct room number within the MAR. Remember to look at the patient name on the MAR to make sure you have the correct patient’s record. Click on Return to Medication Room after reviewing the correct MAR.) Click on Unit Dosage; then click on drawer 406. Select the medication(s) you plan to administer. After each medication you select, click on Put Medication on Tray. When you are finished, click on Close Drawer. Click on View Medication Room. Click on IV Storage. From the close-up view, click on the drawer labeled Large Volume. Select the medication(s) you plan to administer, put medication(s) on tray, and close bin. Click on View Medication Room. Click on Preparation. Select the correct medication to administer; click on Prepare. Supply the information that the Preparation Wizard requests; then click on Next. Choose the correct patient to administer this medication to and click on Finish. Repeat the previous three steps until all medications that you want to administer are prepared. You can click on Review Your Medications and then on Return to Medication Room when ready. From the Medication Room, you may go directly to Patricia Newman's room by clicking on 406 at the bottom of the screen. Administer the medication, utilizing the six rights of medication administration. After you have collected the appropriate assessment data and are ready for administration, click on Patient Care and then on Medication Administration. Verify that the correct patient and medication(s) appear in the left-hand window. Then click the down arrow next to Select. From the drop-down menu, select Administer and complete the Administration Wizard by providing any information requested. When the Wizard stops asking for information, click on Administer to Patient. Specify Yes when asked whether this administration should be recorded in the MAR. Finally, click on Finish. Now let's see how you did! Click on Leave the Floor at the bottom of your screen. From the Floor Menu, select Look at Your Preceptor's Evaluation. Then click on Medication Scorecard. Exercise 2 - Question 13 Note below whether or not you correctly administered the appropriate medications. If not, why do you think you were incorrect? According to Table C in this scorecard, what a