Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
The charge nurse is assigning the nurs-
ing care of a pt who had a left below
the knee amputation 1 day ago to an
experienced LPN/LVN who will function
under your supervision. What will you tell
the LPN/LVN is the major focus for the
pts care today?
b
a. To attain pain control over phantom
pain
b. to monitor for signs of sufficient tissue
perfusion
c. to assist the pt to ambulate asap
d. to elevate the residual limb when the
pt is supine
A pt with a right above the knee amputa-
tion asks you why he has phantom limb
pain. What is your best response?
a. phantom limb pain isn't explained or
predicted by any one theory
b. phantom limb pain occurs because a
your body thinks your leg is still present
c. phantom limb pain will not interfere
with your ADLs
d. phantom limb pain isn't real pain but is
remembered pain
During morning care a pt with a be-
low the knee amputation asks the UAP
about prostheses. How will you instruct
the UAP to respond?
a. you should get a prosthesis so that you
can walk again
d
b. wait and ask your doctor that question
the next time he comes in
c. it's too soon to be worrying about get-
ting a prosthesis
d. i'll ask the nurse to come in and dis-
cuss this with you
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
A pt who underwent a right above the
knee amputation 4 days ago also has a
dx of depression. Which order would you
clarify with the health care provider?
a. give fluoxetine (prozac) 40mg once a
day
b. administer acetaminophen with a
codeine (tylenol-codeine) 1 or 2 tablets
every 4 hours PRN
c. assist the pt to the bedside chair every
shift
d. reinforce the dressing to the right
residual limb as needed
You are admitting an older adult client
to the medical unit. Which assessment
factor alerts you that this client has a risk
for acid base imbalances?
d
a. hx of myocardial infarction 1 yr ago
b. antacid use for occasional indigestion
c. SOB with extreme exertion
d. chronic renal insufficiency
The UAP reports to you that a client
seems very anxious and vs measure-
ment included a respiratory rate of 38
breaths/min. Which acid base imbalance
should you suspect? b
a. respiratory acidosis
b. respiratory alkalosis
c. metabolic acidosis
d. metabolic alkalosis
Mr. W is an 83 yr old man who was
brought to the ER after reporting severe
dyspnea and SOB. He has been experi-
encing coldlike symptoms for the past 2
days. Has a productive cough with thick
green sputum. He is known to have dif-
ficulty breathing even after using his al-
buterol (proventil) metered dose inhaler.
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
He is very anxious and in respiratory
distress. Hx includes COPD related to
smoking 2 packs of cigs/day since he
was 15 yrs old. He has been incontinent
of urine and stool for the past 2 years. In
the ER he undergoes chest radiography
and admission lab tests are performed
including electrolyte levels and a CBC.
A sputum sample is sent to the lab for
b
culture and sensitivity testing and Gram
staining. VS are 152/92 bp, 118 HR, 88%
O2 on 1L oxygen nasal cannula, 38 RR,
100.9F T
What is the priority nursing dx for this pt?
a. decreased cardiac output
b. ineffective airway clearance
c. risk for electrolyte imbalance
d. anxiety
The health care providers order for this
pt include all of the following. Which in-
tervention should you complete first?
a. send an arterial blood gas sample to
the lab
a
b. schedule pulmonary function tests
c. repeat chest radiography each morn-
ing
d. administer albuterol via MDI 2 puffs
every 4 hours
Mr W's ABG results include the following
ph 7.37
PaCO2 55.4
PaO2 51.2
HCO3 38
c
What is your interpretation of these re-
sults?
a. compensated metabolic acidosis with
hypoxemia
b. compensated metabolic alkalosis with
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
hypoxemia
c. compensated respiratory acidosis with
hypoxemia
d. compensated respiratory alkalosis
with hypoxemia
Based on the pts ABG results what are
your priority actions at this time? select
all
a. administer oxygen at 2L/min via nasal
cannula
b. initiate a rapid response
abcf
c. teach the pt how to cough and deep
breathe
d. begin IV normal saline at 100ml/hr
e. arrange a transfer to the ICU
f. remind the pt to practice incentive
spirometry every hour while awake
Which intervention would you assign to
an experienced LPN/LVN?
a. drawing a sample for ABG determina-
tion
b. administering albuterol by hand held d
nebulizer
c. measuring vs every 2 hours
d. increasing oxygen delivery to 2L/min
via nasal cannula
Which interventions could you delegate
to the new UAP? select all
a. helping the pt get up to use the bed-
side commode
b. performing pulse oximetry every shift
c. teaching the pt to cough and deep adf
breathe
d. reminding the pt to use incentive
spirometry every hour while awake
e. assessing the pts breath sounds every
shift
Study online at https://quizlet.com/_4qu2m3
The charge nurse is assigning the nurs-
ing care of a pt who had a left below
the knee amputation 1 day ago to an
experienced LPN/LVN who will function
under your supervision. What will you tell
the LPN/LVN is the major focus for the
pts care today?
b
a. To attain pain control over phantom
pain
b. to monitor for signs of sufficient tissue
perfusion
c. to assist the pt to ambulate asap
d. to elevate the residual limb when the
pt is supine
A pt with a right above the knee amputa-
tion asks you why he has phantom limb
pain. What is your best response?
a. phantom limb pain isn't explained or
predicted by any one theory
b. phantom limb pain occurs because a
your body thinks your leg is still present
c. phantom limb pain will not interfere
with your ADLs
d. phantom limb pain isn't real pain but is
remembered pain
During morning care a pt with a be-
low the knee amputation asks the UAP
about prostheses. How will you instruct
the UAP to respond?
a. you should get a prosthesis so that you
can walk again
d
b. wait and ask your doctor that question
the next time he comes in
c. it's too soon to be worrying about get-
ting a prosthesis
d. i'll ask the nurse to come in and dis-
cuss this with you
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
A pt who underwent a right above the
knee amputation 4 days ago also has a
dx of depression. Which order would you
clarify with the health care provider?
a. give fluoxetine (prozac) 40mg once a
day
b. administer acetaminophen with a
codeine (tylenol-codeine) 1 or 2 tablets
every 4 hours PRN
c. assist the pt to the bedside chair every
shift
d. reinforce the dressing to the right
residual limb as needed
You are admitting an older adult client
to the medical unit. Which assessment
factor alerts you that this client has a risk
for acid base imbalances?
d
a. hx of myocardial infarction 1 yr ago
b. antacid use for occasional indigestion
c. SOB with extreme exertion
d. chronic renal insufficiency
The UAP reports to you that a client
seems very anxious and vs measure-
ment included a respiratory rate of 38
breaths/min. Which acid base imbalance
should you suspect? b
a. respiratory acidosis
b. respiratory alkalosis
c. metabolic acidosis
d. metabolic alkalosis
Mr. W is an 83 yr old man who was
brought to the ER after reporting severe
dyspnea and SOB. He has been experi-
encing coldlike symptoms for the past 2
days. Has a productive cough with thick
green sputum. He is known to have dif-
ficulty breathing even after using his al-
buterol (proventil) metered dose inhaler.
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
He is very anxious and in respiratory
distress. Hx includes COPD related to
smoking 2 packs of cigs/day since he
was 15 yrs old. He has been incontinent
of urine and stool for the past 2 years. In
the ER he undergoes chest radiography
and admission lab tests are performed
including electrolyte levels and a CBC.
A sputum sample is sent to the lab for
b
culture and sensitivity testing and Gram
staining. VS are 152/92 bp, 118 HR, 88%
O2 on 1L oxygen nasal cannula, 38 RR,
100.9F T
What is the priority nursing dx for this pt?
a. decreased cardiac output
b. ineffective airway clearance
c. risk for electrolyte imbalance
d. anxiety
The health care providers order for this
pt include all of the following. Which in-
tervention should you complete first?
a. send an arterial blood gas sample to
the lab
a
b. schedule pulmonary function tests
c. repeat chest radiography each morn-
ing
d. administer albuterol via MDI 2 puffs
every 4 hours
Mr W's ABG results include the following
ph 7.37
PaCO2 55.4
PaO2 51.2
HCO3 38
c
What is your interpretation of these re-
sults?
a. compensated metabolic acidosis with
hypoxemia
b. compensated metabolic alkalosis with
, Prioritization Questions/Evolve HESI case studies NURS 309
Study online at https://quizlet.com/_4qu2m3
hypoxemia
c. compensated respiratory acidosis with
hypoxemia
d. compensated respiratory alkalosis
with hypoxemia
Based on the pts ABG results what are
your priority actions at this time? select
all
a. administer oxygen at 2L/min via nasal
cannula
b. initiate a rapid response
abcf
c. teach the pt how to cough and deep
breathe
d. begin IV normal saline at 100ml/hr
e. arrange a transfer to the ICU
f. remind the pt to practice incentive
spirometry every hour while awake
Which intervention would you assign to
an experienced LPN/LVN?
a. drawing a sample for ABG determina-
tion
b. administering albuterol by hand held d
nebulizer
c. measuring vs every 2 hours
d. increasing oxygen delivery to 2L/min
via nasal cannula
Which interventions could you delegate
to the new UAP? select all
a. helping the pt get up to use the bed-
side commode
b. performing pulse oximetry every shift
c. teaching the pt to cough and deep adf
breathe
d. reminding the pt to use incentive
spirometry every hour while awake
e. assessing the pts breath sounds every
shift
