n doing the admission assessment on Mr. Sims, the nurse notes adventitious breath sounds in bilateral lower lung fields. What adventitious lung sounds would the nurse most expect to hear given Mr. Sim's presentation described above? crackles
The physician has just rounded and ordered that an indwe...
NSG 321 Final Exam Review Questions
and Solutions
In doing the admission assessment on Mr. Sims, the nurse notes adventitious breath
sounds in bilateral lower lung fields. What adventitious lung sounds would the nurse
most expect to hear given Mr. Sim's presentation described above? ✅crackles
The physician has just rounded and ordered that an indwelling urinary catheter be
placed so that urinary output can be closely monitored. While performing the procedure,
the nurse knows that which actions would contaminate sterility? Select all that apply.
✅- Leaving the bed in the lowest position to promote patient safety during the
procedure
- Pulling used cotton balls back over the sterile field and box to catch any dripping of the
cleaning solution
- Opening the box with the first flap removed being the one closest to the nurse
Two hours later, Mr. Sims reports feeling increasingly dyspneic. His SPO2 has declined
to 85%. He remains on 4L/NC and continues to have bibasilar adventitious breath
sounds. After calling the doctor, the nurse receives the following instructions:
- Obtain an EKG now
- 80mg IV furosemide now
- Increase FiO2 to 100%, then down titrate as possible to keep SPO2 >92%
- ABGs after 15 minutes on 100%
Which new order should be the first priority for the nurse to implement? ✅Increase
FiO2
To increase the FiO2 to 100% as the physician ordered, which supplemental oxygen
delivery device should the nurse choose? ✅non-rebreather mask
In doing a later assessment, the nurse looks at Mr. Sims' catheter. Given the image
below, what intervention should the nurse perform at this time? ✅The nurse should
rearrange the tubing to allow better drainage of the urine.
After the 80mg dose of furosemide, Mr. Sims has diuresed 600mL over the past 2
hours. His resp effort is now even and unlabored, and the nurse decided it might be
time to try to wean down the FiO2. Which signs and symptoms should the nurse be
monitoring to ensure the patient is tolerating the decreased FiO2? Select all that apply.
✅- peripheral oxygen saturation (SpO2)
- respiratory rate
- skin tone
- work of breathing
, Two days later, the nurse caring for Mr. Sims recognized that he had become confused.
He is alert but disoriented to time and place. Vital signs are:
BP 84/40
RR 26
HR 114
SpO2 96% on 6L/NC
Temp 102.5 (oral temp)
What should be the nurse's priority intervention after this assessment? ✅Contact the
physician to report findings
Mr. Sims' daughter has come in to visit today and asks the nurse why her father is
confused and has a fever. Given the symptoms (His symptoms: fever and
disorientation) described in the question above, what problem does the nurse think is
most likely given the patient's situation?
(Think about the "Diagnosis" part of the nursing process - what is the most likely
problem?) ✅catheter associated infection
- His symptoms:
fever, disorientation- are classic signs of UTI in an older adult
but also given that he got a catheter 2 days ago - that has to be your primary concern.
Of note, his hypotension and tachycardia are concerning that his infection is causing a
systemic body response - this is becoming increasingly urgent.
In this patient's specific case, what is the rationale for giving the pain medication via the
IV route? Select all that apply ✅- The patient has been vomiting, so oral medications
may not be well tolerated.
- Giving medications intravenously allow faster onset of action.
- Intravenous medications are more potent than oral medications.
It is now 11am. Mr. Stone is complaining that his pain has returned. What intervention
should the nurse undertake now? ✅contact the provider
After administering the medication, what signs would the nurse assess for to evaluate
the effectiveness of the medication? Select all that apply ✅- Assess the patient's pain
scale
- Assess the patient's subjective report of pain
Three days later, the nurse is assessing Mr. Stone. He still reports 6/10 pain and is
requiring IV pain medications. His vitals are:
HR 102
Temp 101.3
BP 114/74
RR 22
I
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