Founcations Of Nursing- Clinical

1. You greeted your patient, introduced yourself, and ask the patient to tell you his name, date of birth, today's date, and which hospital he is at now. Your patient answered all these question correctly and was smiling. His level of consciousness is:

Alert, awake, oriented, and cheerful

Confused

Withdrawal

Comatose

The patient's ability to correctly answer questions about his name, date of birth, today's date, and the hospital indicates that he is alert and oriented to person, time, and place. Additionally, his cheerful demeanor suggests that he is awake and in a positive mood. Therefore, the patient's level of consciousness can be described as alert, awake, oriented, and cheerful.

Explanation

The patient's ability to correctly answer questions about his name, date of birth, today's date, and the hospital indicates that he is alert and oriented to person, time, and place. Additionally, his cheerful demeanor suggests that he is awake and in a positive mood. Therefore, the patient's level of consciousness can be described as alert, awake, oriented, and cheerful.

2. As you continued your assessment, you found that patient's hands and feet swollen with fluid under the skin, what do we call this condition?

Dehydration

Edema

Internal bleeding

Inflammation

Edema is the correct answer because it refers to the swelling caused by the accumulation of fluid under the skin. This condition can occur due to various reasons such as fluid retention, kidney disease, heart failure, or certain medications. It is important to identify and treat the underlying cause of edema to alleviate the swelling and prevent further complications. Dehydration, internal bleeding, and inflammation are not appropriate terms to describe the given symptom of swollen hands and feet.

Explanation

Edema is the correct answer because it refers to the swelling caused by the accumulation of fluid under the skin. This condition can occur due to various reasons such as fluid retention, kidney disease, heart failure, or certain medications. It is important to identify and treat the underlying cause of edema to alleviate the swelling and prevent further complications. Dehydration, internal bleeding, and inflammation are not appropriate terms to describe the given symptom of swollen hands and feet.

3. It is time to give your patient his anti-hypertension medication. The patient is taking norvasc and coreg. His current blood pressure is 155/49. The patient asked you about the difference between the two "blood pressure" medicine, what would you say?

There is no difference, but you need both because your BP is pretty high

One is very expensive and other one is cheap

They both lower the high BP, but have two different mechanism

I really do not know, you can ask your doctor

The answer states that both Norvasc and Coreg lower high blood pressure, but they work through different mechanisms. This means that they target different pathways in the body to achieve the same goal of reducing blood pressure. It implies that both medications are necessary to effectively manage the patient's high blood pressure.

Explanation

The answer states that both Norvasc and Coreg lower high blood pressure, but they work through different mechanisms. This means that they target different pathways in the body to achieve the same goal of reducing blood pressure. It implies that both medications are necessary to effectively manage the patient's high blood pressure.

4. Your are working with a nurse at Med-Surg floor. The nurse just received a report from E.R. about a patient who will be transferred to your floor. You asked your nurse to tell you a little bit about the patient. She replied: He is a 74 years old male, came with mild shortness of breathe (SOB). He is alert, awake, with +3 edema in the ankles bilaterally. His vital signs in ER are: BP 156/34, pulse, 92, Temp, 98.1 F, respiration 28, SpO2 93% at nasal cannula 3 L/min. Based on these information, which of the following is most likely the medical diagnosis of this patient? What is your best guess?

Sepsis

Congestive Heart Failure (CHF)

Altered level of consciousness

CVA

Based on the given information, the patient is a 74-year-old male who presented with mild shortness of breath and has bilateral ankle edema. His vital signs show elevated blood pressure, slightly increased heart rate, normal temperature, increased respiratory rate, and decreased oxygen saturation. These findings are consistent with congestive heart failure (CHF). CHF is a condition where the heart is unable to pump enough blood to meet the body's needs, leading to fluid accumulation in the lungs and peripheral edema. Therefore, CHF is the most likely medical diagnosis for this patient.

Explanation

Based on the given information, the patient is a 74-year-old male who presented with mild shortness of breath and has bilateral ankle edema. His vital signs show elevated blood pressure, slightly increased heart rate, normal temperature, increased respiratory rate, and decreased oxygen saturation. These findings are consistent with congestive heart failure (CHF). CHF is a condition where the heart is unable to pump enough blood to meet the body's needs, leading to fluid accumulation in the lungs and peripheral edema. Therefore, CHF is the most likely medical diagnosis for this patient.

5. You thanked your patient for the information. Now your are going to tell him briefly about the routine in the floor. Which of the following information should be mentioned?

We will take your vital signs once a day

You should not expect to have enough sleep here

If you need anything you can use the calling bell to call for me

Your family can bring you the food that you like

The information about using the calling bell to call for assistance should be mentioned because it is relevant to the patient's needs and ensures that they are aware of how to get help if needed.

Explanation

The information about using the calling bell to call for assistance should be mentioned because it is relevant to the patient's needs and ensures that they are aware of how to get help if needed.

6. You informed the physician about the bruises. He said "we need to check his coagulation." Which of the following is coagulation test?

CBC

PTT, PT, INR

Blood culture

BMP

The physician's statement indicates the need to check the patient's coagulation, which refers to the blood's ability to form clots. PTT (Partial Thromboplastin Time), PT (Prothrombin Time), and INR (International Normalized Ratio) are all tests used to evaluate the coagulation process. These tests measure the time it takes for blood to clot and can help diagnose clotting disorders or monitor the effectiveness of anticoagulant medications. Therefore, the correct answer is PTT, PT, INR.

Explanation

The physician's statement indicates the need to check the patient's coagulation, which refers to the blood's ability to form clots. PTT (Partial Thromboplastin Time), PT (Prothrombin Time), and INR (International Normalized Ratio) are all tests used to evaluate the coagulation process. These tests measure the time it takes for blood to clot and can help diagnose clotting disorders or monitor the effectiveness of anticoagulant medications. Therefore, the correct answer is PTT, PT, INR.

7. What is the name of the device in the picture above?

The device in the picture above is a pacemaker. A pacemaker is a small electronic device that is implanted in the chest or abdomen to help control abnormal heart rhythms. It uses electrical pulses to regulate the heart's rhythm and ensure it beats at a steady pace. Pacemakers are commonly used to treat conditions such as bradycardia (slow heart rate) or arrhythmias (irregular heart rhythms).

Explanation

The device in the picture above is a pacemaker. A pacemaker is a small electronic device that is implanted in the chest or abdomen to help control abnormal heart rhythms. It uses electrical pulses to regulate the heart's rhythm and ensure it beats at a steady pace. Pacemakers are commonly used to treat conditions such as bradycardia (slow heart rate) or arrhythmias (irregular heart rhythms).

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8. You saw that the IV is connected to an infusing pump. The pump screen reads 50. How many mL of IV fluid is being infused for this patient every 4 hours?

50

100

150

200

The IV pump screen reading of 50 indicates that the infusion rate is set at 50 mL/hour. Since the question asks for the amount of IV fluid infused every 4 hours, we can calculate it by multiplying the infusion rate by the duration. Therefore, 50 mL/hour multiplied by 4 hours equals 200 mL.

Explanation

The IV pump screen reading of 50 indicates that the infusion rate is set at 50 mL/hour. Since the question asks for the amount of IV fluid infused every 4 hours, we can calculate it by multiplying the infusion rate by the duration. Therefore, 50 mL/hour multiplied by 4 hours equals 200 mL.

9. A phlebotomist came from the lab and took a blood sample for coagulation. He called you after 30 minutes to informed you with critical results: PT= 58. You are going to informed the physician of this result, what you expect the physician to order?

Continue coumadin as ordered

No order, just observe the patient

Stop coumadin and give vitamin K

Transfuse 2 units of blood

Based on the given information, the phlebotomist took a blood sample for coagulation and the PT (Prothrombin Time) result was 58, which is considered critical. PT measures the time it takes for blood to clot, and a higher value indicates a longer clotting time. Coumadin is a medication that is used to prevent blood clotting, so stopping coumadin would be appropriate in this situation. Giving vitamin K is also a suitable action because vitamin K helps in the production of clotting factors in the blood. Therefore, the correct answer is to stop coumadin and give vitamin K.

Explanation

Based on the given information, the phlebotomist took a blood sample for coagulation and the PT (Prothrombin Time) result was 58, which is considered critical. PT measures the time it takes for blood to clot, and a higher value indicates a longer clotting time. Coumadin is a medication that is used to prevent blood clotting, so stopping coumadin would be appropriate in this situation. Giving vitamin K is also a suitable action because vitamin K helps in the production of clotting factors in the blood. Therefore, the correct answer is to stop coumadin and give vitamin K.

10. While you were doing your assessment, you noticed several bruises in the patient's skin. You also noticed this (see the picture) in his left upper chest. Which of the following medication has caused the bruises?

Lasix

Nitroglycerin

Coreg

Coumadin

Coumadin, also known as warfarin, is an anticoagulant medication that is commonly prescribed to prevent blood clots. One of the side effects of Coumadin is an increased risk of bleeding, which can manifest as bruises on the skin. Therefore, it is likely that Coumadin is the medication responsible for causing the bruises observed on the patient's skin. Lasix, Nitroglycerin, and Coreg are not typically associated with bruising as a side effect.

Explanation

Coumadin, also known as warfarin, is an anticoagulant medication that is commonly prescribed to prevent blood clots. One of the side effects of Coumadin is an increased risk of bleeding, which can manifest as bruises on the skin. Therefore, it is likely that Coumadin is the medication responsible for causing the bruises observed on the patient's skin. Lasix, Nitroglycerin, and Coreg are not typically associated with bruising as a side effect.

11. While you're waiting for ER staff to bring the patient to your floor, you decide to look up his laboratory work. You find the following:
Na: 129, K: 5.9, BUN: 15, Cr. 1.1, Hb: 14.1, WBC: 9.2. Which of these laboratory results is/are abnormal?

Na, K, and BUN

Na, K, and Hb

Na, K, Hb, and WBC

Na and K only

The normal range for sodium (Na) in the blood is typically between 135-145 mEq/L, and the given value of 129 mEq/L is below the normal range, indicating an abnormal result. The normal range for potassium (K) in the blood is typically between 3.5-5.0 mEq/L, and the given value of 5.9 mEq/L is above the normal range, indicating an abnormal result. The other laboratory results, including BUN, Hb, and WBC, fall within the normal range. Therefore, the correct answer is Na and K only.

Explanation

The normal range for sodium (Na) in the blood is typically between 135-145 mEq/L, and the given value of 129 mEq/L is below the normal range, indicating an abnormal result. The normal range for potassium (K) in the blood is typically between 3.5-5.0 mEq/L, and the given value of 5.9 mEq/L is above the normal range, indicating an abnormal result. The other laboratory results, including BUN, Hb, and WBC, fall within the normal range. Therefore, the correct answer is Na and K only.

12. Based on the information from ER and chest x-ray, when you auscultate the patient's lungs with the patient in high Fowler's position, you expect to hear:

Regular breathing sounds

Crackles, which indicate presence of fluid

Wheezing, which indicates airway narrowing

Diminished breathing sounds all over the chest

When auscultating the patient's lungs in high Fowler's position, crackles are expected to be heard. Crackles are abnormal lung sounds that indicate the presence of fluid in the lungs. This can be a sign of conditions such as pneumonia, pulmonary edema, or congestive heart failure. Auscultating crackles helps in diagnosing and monitoring these conditions. Regular breathing sounds would be expected in a healthy individual, wheezing indicates airway narrowing, and diminished breathing sounds all over the chest may suggest conditions like atelectasis or pneumothorax.

Explanation

When auscultating the patient's lungs in high Fowler's position, crackles are expected to be heard. Crackles are abnormal lung sounds that indicate the presence of fluid in the lungs. This can be a sign of conditions such as pneumonia, pulmonary edema, or congestive heart failure. Auscultating crackles helps in diagnosing and monitoring these conditions. Regular breathing sounds would be expected in a healthy individual, wheezing indicates airway narrowing, and diminished breathing sounds all over the chest may suggest conditions like atelectasis or pneumothorax.

13. As part of your assessment, you next obtained the vital signs, which were:
BP 163/45, Temp 99.1, HR 81, SpO2 95%, Respiration 23, pain 0/10. Based on these readings, the patient is having:

Hypotension and hyperthemia

Hypertension and tachycardia

Hypertension and tachypnea

Hypertension and desaturation

The patient's blood pressure reading of 163/45 indicates hypertension, while the respiratory rate of 23 suggests tachypnea. Tachypnea is an increased respiratory rate, which can be a sign of various conditions including anxiety, fever, or respiratory distress. Therefore, based on these readings, the patient is experiencing hypertension and tachypnea.

Explanation

The patient's blood pressure reading of 163/45 indicates hypertension, while the respiratory rate of 23 suggests tachypnea. Tachypnea is an increased respiratory rate, which can be a sign of various conditions including anxiety, fever, or respiratory distress. Therefore, based on these readings, the patient is experiencing hypertension and tachypnea.

14. During your assessment, you find a pink IV catheter in the right arm. What is the gauge of this pink IV?

18

20

22

24

The pink IV catheter is most likely a 20 gauge. IV catheters come in different colors to indicate their size or gauge. Pink is commonly associated with a 20 gauge IV catheter. The gauge refers to the diameter of the catheter, with a smaller gauge indicating a larger diameter. Therefore, a 20 gauge catheter is larger than a 22 or 24 gauge, but smaller than an 18 gauge.

Explanation

The pink IV catheter is most likely a 20 gauge. IV catheters come in different colors to indicate their size or gauge. Pink is commonly associated with a 20 gauge IV catheter. The gauge refers to the diameter of the catheter, with a smaller gauge indicating a larger diameter. Therefore, a 20 gauge catheter is larger than a 22 or 24 gauge, but smaller than an 18 gauge.

15. When you assess the apical pulse, which of the following will be most likely finding?

Regular tachycardia

Irregular tachcardia

Normal heart rate and rhythm

Irregular heart rate and rhythm

When assessing the apical pulse, an irregular heart rate and rhythm would be the most likely finding. This means that the heartbeats are occurring at irregular intervals and may have an irregular pattern. This could be indicative of an underlying heart condition or arrhythmia. Regular tachycardia would imply a consistently fast heart rate, while irregular tachycardia would suggest a fast heart rate with irregular intervals. A normal heart rate and rhythm would not show any irregularities.

Explanation

When assessing the apical pulse, an irregular heart rate and rhythm would be the most likely finding. This means that the heartbeats are occurring at irregular intervals and may have an irregular pattern. This could be indicative of an underlying heart condition or arrhythmia. Regular tachycardia would imply a consistently fast heart rate, while irregular tachycardia would suggest a fast heart rate with irregular intervals. A normal heart rate and rhythm would not show any irregularities.

16. Based on your assessment, you found that the patient is at risk for fall RT edema, antiHTN medication, connected IV.. which of the following should be done next:

Have a green band around the patient's hand

Raised 4 side rails

Encourage the patient to call you for help

Have a family member sit with patient all the time

Encouraging the patient to call for help is the most appropriate action to take in this situation. The patient is at risk for falls due to factors such as edema, antiHTN medication, and being connected to an IV. By encouraging the patient to call for help, they can alert the healthcare provider if they feel unsteady or need assistance with mobility. This allows for timely intervention and reduces the risk of falls and potential injuries. The other options, such as having a green band around the patient's hand, raising all four side rails, or having a family member sit with the patient, may not directly address the immediate need for assistance and may not be the most effective course of action.

Explanation

Encouraging the patient to call for help is the most appropriate action to take in this situation. The patient is at risk for falls due to factors such as edema, antiHTN medication, and being connected to an IV. By encouraging the patient to call for help, they can alert the healthcare provider if they feel unsteady or need assistance with mobility. This allows for timely intervention and reduces the risk of falls and potential injuries. The other options, such as having a green band around the patient's hand, raising all four side rails, or having a family member sit with the patient, may not directly address the immediate need for assistance and may not be the most effective course of action.

17. Your patient is in your floor now. You and the ER nurse assisted the patient in moving from the gurney to his bed. Now its time for quick physical assessment. Your patient looks stable now, What is the first system you should assess?

Respiratory

Cardiovascular

Neurological

GI

The first system that should be assessed is the neurological system. This is because even though the patient may appear stable, any changes in their neurological status could indicate a serious underlying condition. Assessing the patient's level of consciousness, orientation, motor function, and sensory function can provide important information about their overall neurological status and help determine the appropriate course of treatment.

Explanation

The first system that should be assessed is the neurological system. This is because even though the patient may appear stable, any changes in their neurological status could indicate a serious underlying condition. Assessing the patient's level of consciousness, orientation, motor function, and sensory function can provide important information about their overall neurological status and help determine the appropriate course of treatment.

18. So far, what is the best nursing diagnosis?

Pain

Decreased cardiac output

Impaired gas exchange

Impaired skin integrity

Impaired gas exchange is considered the best nursing diagnosis among the given options because it refers to the inadequate oxygenation and/or ventilation in the lungs, which can lead to respiratory distress. This diagnosis is important as it can have serious consequences on the patient's overall health and well-being. Nurses can implement interventions to improve gas exchange, such as administering supplemental oxygen, monitoring respiratory status, and promoting proper breathing techniques.

Explanation

Impaired gas exchange is considered the best nursing diagnosis among the given options because it refers to the inadequate oxygenation and/or ventilation in the lungs, which can lead to respiratory distress. This diagnosis is important as it can have serious consequences on the patient's overall health and well-being. Nurses can implement interventions to improve gas exchange, such as administering supplemental oxygen, monitoring respiratory status, and promoting proper breathing techniques.

19. Thirty minutes later, your patient called your and told you that his SOB became worse. You checked his respiration and O2 sat and found: RR 31, O2 sat 88%. The patient is currently on nasal cannual. You informed the respiratory therapist and now both of you need to decide to replace the nasal cannula, which of the following oxygen modalities would you choose?

Room air

Keep the nasal cannula and increase the oxygen flow to 15 liters

Non-rebreathing mask, which gives oxygen up to 100%

Oxymizer

Given the patient's worsening shortness of breath and low oxygen saturation, it is necessary to provide a higher concentration of oxygen. The oxymizer is a device that conserves and delivers a higher percentage of oxygen compared to a nasal cannula. It is a suitable choice to improve the patient's oxygenation and alleviate their symptoms.

Explanation

Given the patient's worsening shortness of breath and low oxygen saturation, it is necessary to provide a higher concentration of oxygen. The oxymizer is a device that conserves and delivers a higher percentage of oxygen compared to a nasal cannula. It is a suitable choice to improve the patient's oxygenation and alleviate their symptoms.