TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing clinical nu, Exams of Nursing

Download TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing clinical nu and more Exams Nursing in PDF only on Docsity! TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing clinical nursing skills and techniques perry & potter 9TH EDITION, Exams of Nursing A nurse receives a home referral for a client recently hospitalized for heart failure. In preparation for her initial visit, the nurse reviews the referral report. The client is a 79-year-old woman who lives with her 59-year-old sister in a split-level four-bedroom home that she has owned for over 50 years. She has a history of osteoporosis and early-onset Parkinson disease. The client is prescribed to take both a diuretic and an angioten- sin-converting enzyme inhibitor for heart failure. This is in addition to her medications for Parkinson and glaucoma. She has advanced glaucoma and diminished hearing but does not TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing wear hearing aids. The sister is employed as a service worker at a local elementary school. The sister reportedly provides assistance when the client has difficulty with ADL activities. The home referral is aimed at assessment of the client's home situation and any health implications. After reviewing the - ✔✔ANSWER✔✔-1. Fatigue 3. Cognitive change 4. Reduced depth perception 5. Impaired gait - The patient's heart failure can cause fatigue, which is a risk factor for falling. The risk for falling is also the case with cognitive change and impaired gait, possible findings in a patient with Parkinson's disease. The patient's glaucoma could cause reduced depth perception. The patient's referral history does not include a condition that typically causes joint discomfort. Hearing acuity can predispose to injury but is not a risk factor for falling. TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing 5. Condition of furniture in living room - ✔✔ANSWER✔✔-3. Condition of lighting over sink, stove, and work area - The one hazard likely posed in relationship to the client having glaucoma is the condition of lighting. Adequate, no-glare light- ing is needed. Hazards 1 and 2 are important in the relationship to the client having Parkinson disease. The client is likely to have an un- steady gait and needs side rails for support when climbing stairs. Pres- ence of throw rugs can cause the client to easily trip, especially with an unsteady gait. Hazards 4 and 5 are part of a routine home. The nurse visits the client again, 7 days later. The client has missed two doses of the diuretic ordered for her heart failure. The client has difficulty recalling the times her medications are due. The nurse asks the client if the client's sister can be involved in a discussion regarding ways to improve medication adherence. The client agrees. What is the first priority for the nurse to consider before involving the sister in the plan of care? 1.Sister's health literacy TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing 2.Sister's concerns about being able to care for client 3.Sister's willingness to make changes to home environment 4.Sister's functional limitations affecting his or her ability to assist client - ✔✔ANSWER✔✔-4. Sister's functional limitations affecting his or her ability to assist client - The daughter must have the physical and mental capacity to assist her mother. The nurse cannot assume that since the daughter is employed, she has the physical abilities needed to help the mother prepare medications. If she does not, other resources or approaches are necessary. Health literacy is the next priority. If the sister is able to as- sist, what level of explanation is needed? The sister's concerns about being able to care for the client also need to be identified. oxygen therapy - ✔✔ANSWER✔✔-the administration of supplement oxygen. Hypoxia - ✔✔ANSWER✔✔-a condition in which there is insufficient oxygen to meet the metabolic demands at the tissues and cells. TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing Signs and symptoms of hypoxia are - ✔✔ANSWER✔✔- apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes Hemoglobin (Hgb) - ✔✔ANSWER✔✔-is the carrier of respiratory gases, oxygen, and carbon dioxide decreased hemoglobin levels reduce the amount of - ✔✔ANSWER✔✔-oxygen transported to the cells and carbon dioxide transported away from the cells hemoglobin levels and acid-base Status directly affect - ✔✔ANSWER✔✔-oxygenation acidemia - ✔✔ANSWER✔✔-increases the ability of hemoglobin to release oxygen to tissues alkalemia decreases the ability - ✔✔ANSWER✔✔-of hemoglobin to release oxygen to the tissue TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing Smoking resulting in decreased ability to - ✔✔ANSWER✔✔- clear mucus from the airways. chronic bronchitis is caused by - ✔✔ANSWER✔✔-smoking and results in pooling of mucus in the airways, creating environment for the development of infections. long-term chronic bronchitis ultimately results in - ✔✔ANSWER✔✔-hypoxia ABG - ✔✔ANSWER✔✔-arterial blood gas values Oxygen is medication. Increase the flow rate of oxygen for shortness of breath is equal to - ✔✔ANSWER✔✔-doubling heart, asthma, or other medication. Have suction equipment available to help clear airway secretions, particularly in patients with - ✔✔ANSWER✔✔- artificial airways such an endotracheal tube or tracheostomy. TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing Most agencies require what should be available in the room with patient requiring mechanical ventilation. - ✔✔ANSWER✔✔-self-inflating resuscitation bag and appropriate-size mask What are the diseases that need oxygen therapy - ✔✔ANSWER✔✔-COPD Chronic Obstructive pulmonary Disease, Pneumonia Pneumonia results in impaired gas exchange because of - ✔✔ANSWER✔✔-fluid and secretions in the lung, which decrease the diffusion of oxygen from the lungs to the arterial blood supply. long term oxygen therapy can improve survival in - ✔✔ANSWER✔✔-COPD High flow devices discourage entraining room air, which dilutes - ✔✔ANSWER✔✔-the inspired oxygen concentration. TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing oxygen cylinders in the hospital include - ✔✔ANSWER✔✔-H cylinder and E cylinder unexpected outcome patient experiences hypoxia, hypercapnia, or other signs of worsening respiratory function - ✔✔ANSWER✔✔-notify health care provider, reassess patient, determine correct settings Integrity of the n i p pv patient develops skin breakdown at Mask sites or sites where Mask straps are located such as the bridge of the nose, nasal septum, or ears. - ✔✔ANSWER✔✔-notify health care provider, Place protective synthetic coverings on nasal Bridge or areas of irritation possible irritation to protect skin, fit mask so it is tight enough to not cause air leak but Loose enough to not cause skin breakdown for patients who have measurable changes in the flow their Airway such as patients with - ✔✔ANSWER✔✔-asthma or reactive airway disease, Peak expiratory flow rate PEFR measurements are useful TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing low pressure alarm sounds when the ventilator has no - ✔✔ANSWER✔✔-resistance to inflating the cologne Dyspnea - ✔✔ANSWER✔✔-shortness of breath Tachypnea - ✔✔ANSWER✔✔-more than 20 breaths/min bloody sputum is - ✔✔ANSWER✔✔-hemopytsis Patients with artificial airway - ✔✔ANSWER✔✔-require constant humidification to the airway since it bypasses the nose and mouth of normal filtering. The two devices that supply humidified gas to an artifical airway are a - ✔✔ANSWER✔✔-T tube Briggs adaptor and a tracheostomy collar. Unexpected Outcomes: TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing patient experiences tracheal stoma or lip irritation; thick, tenacious secretions; pressure areas on neck or near stoma site. - ✔✔ANSWER✔✔-Implement measures to protect patient from medical device pressure injuries (MDPI's) Increase frequency of suctioning and airway care Unexpected Outcomes: patient experiences continued hypoxia - ✔✔ANSWER✔✔- Determine if cause of continued hypoxia is oxygen-delivery device, plugging of airway, oxygen flow rate, or a new clinical problem. Notify health care provider of continued or worsening hypoxia. Flow orientated IS's have - ✔✔ANSWER✔✔-one or more plastic chambers with freely movable colored balls. Advantage is slow, steady expansion of the lung Volume-oriented devices use a bellows that a patient must - ✔✔ANSWER✔✔-raise to a predetermined volume by inhaling slowly. Advantage of this is that patient can achieve a known inspiratory volume and measure it with each breath. TEST BANK CLINICAL NURSING SKILLS AND TECHNIQUES 9TH EDITION, Exams of Nursing Prescribed timing schedules of IS use are up to - ✔✔ANSWER✔✔-30 deep breaths with 30 to 60 second rests between sets of 10. Older adults with chronic - ✔✔ANSWER✔✔-illnesses or arthritis have difficulty coordinating the use of the IS. They require additional time to demonstrate the procedure. Older adults have weakened - ✔✔ANSWER✔✔-respiratory muscles and decreased elastic recoil properties of the lungs affect a patients ability to cough and deep breathe. So it takes longer to achieve the target volume. An older adult may be more able to use - ✔✔ANSWER✔✔-the volume-oriented IS versus the flow-oriented IS.