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Case Study, Chapter 11, Health Care of the Older Adult 1. The nurse working at the senior center notices Mrs. Jones, a 78-year-old, crying. The nurse approaches Mrs. Jones and asks if she needs help. Mrs. Jones states “I am so embarrassed. I had another accident and my pants are all wet. It’s like I’m a baby. I never should have come to the senior center.” a. What factors may be contributing to the urinary incontinence? b. How should the nurse respond to Mrs. Jones? 2. The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history. a. What questions should the nurse include in the medication history? b. The patient states that she stopped taking one of her medications due to cost, since her health insurance would not reimburse for the medication. What are other reasons that older adults may be noncompliant with ordered medications? c. Fundamentals of nursing
How does aging affect drug absorption, metabolism, distribution, and excretion? Case Study, Chapter 12, Pain Management 1. Mr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and Oxycodone 10 mg every 4 hours PRN for severe pain. a. Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why? b. What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring? c. What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management? 2. Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82. a. What are benefits of epidural ver sus systemic administration of opioids? b. The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. Fundamentals of nursing
What is the rationale for these frequent assessments? c. The nurse monitors Mr. Rogers for what other complications of epidural analgesia? d. Mr. Rogers complains of a severe headache. What should the nurse do? e. Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation? Case Study, Chapter 13, Fluid and Electrolytes: Balance and Disturbance 1. Mrs. Dean is 75-year-old woman admitted to the hospital for a small bowel obstruction. Her medical history includes hypertension. Mrs. Dean is NPO. She has a nasogastric (NG) tube to low continuous suction. She has an IV of 0.9% NS at 83 mL/hr. Current medications include furosemide 20 mg daily and hydromorphone 0.2 mg every 4 hours, as needed for pain. The morning electrolytes reveal serum potassium of 3.2 mEq/L. a. What are possible causes of a low potassium level? b. What action should the nurse take in relation to the serum potassium level? c. What clinical manifestations might the nurse assess in Mrs. Dean? 2. Conrad Jackson is a 28-year-old man who presents to the emergency department with severe fatigue and dehydration secondary to a 4-day history of vomiting. During the interview, he describes attending a family reunion and states that perhaps he “ate something bad.” Upon admission his vital signs are a temperature of 102.7°F, heart rate of 116 bpm, respiratory rate of 18 breaths/min, and blood pressure of 86/54 mm Hg. The nurse also notes the patient has dry mucous membranes and tenting of skin. The physician orders an IV to be started with 0.45% normal saline, and orders a serum electrolytes and an arterial blood gas. The following results are returned from the laboratory: Sodium (Na+) 150 Potassium (K+) 5.5 Chloride (Cl¯) 110 BUN 42 Creatinine 0.8 Glucose 86 pH 7.32 PaCO2 35 HCO3¯ 20 PaO2 90 O2 Sat 98% a. What is your interpretation of this arterial blood gas sample? b. Explain the high potassium in this patient. c. Calculate the patient’s anion gap: d. What is the interpretation of this anion gap? Case Study, Chapter 14, Shock and Multiple Organ Dysfunction Syndrome 1. Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments.Fundamentals of nursing
The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. a. What predisposed the patient to develop septic shock? b. What potential findings would suggest that the patient’s septic shock is worsening from the point of admission? c. The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication? d. Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient? e. Explain the importance for nutritional support for this patient and which type of nutritional support should be provided? 2. Carlos Adams was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are as follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented, but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock. Fundamentals of nursing
The following orders are written for the patient: Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/line Obtain complete blood count, serum electrolytes Oxygen at 2 L/min via nasal cannula Type and cross for 4 units of blood Flat plate of the abdomen STAT (Learning Objectives 1, 4, and5) a. Fundamentals of nursing
Describe the pathophysiologic sequence of events seen with hypovolemic shock. b. What are the major goals of medical management in this patient? c. What is the rationale for placing two large-bore IVs? d. What are advantages of using 0.9% NS in this patient? e. What is the rationale for placing the patient in a modified Trendelenburg position? Case Study, Chapter 15, Oncology: Nursing Management in Cancer Care 1. Emanuel Jones, 60 years of age, is male patient diagnosed with small cell carcinoma. He underwent surgery in the past to remove the left lower lobe of his lung. He is receiving chemotherapy. Two weeks before a round of chemotherapy, a complete blood count with differential, and a renal and metabolic profile are obtained for the patient. The patient presents to the oncology clinic for chemotherapy with a temperature of 101°F. Further assessment reveals decreased breath sounds in the right base of the right lung, and a productive cough expectorating green colored mucus. The patient is short of breath and has a pulse oximetry reading that is SaO2 of 85% on room air. The patient has a history of benign prostate hypertrophy (BPH) and has complaints of urinary frequency and burning upon urination. The patient is admitted to the oncology unit in the hospital. The oncologist orders the following: blood, sputum, and urine cultures; and a chest x-ray. An x-ray of the kidneys, ureters, bladder (KUB) is ordered. An arterial blood gas (ABG) on room air, CBC with differential, and renal and metabolic profile are ordered. Oxygen is ordered to begin with nasal cannula at 2 L/min and titrate to keep SaO2 greater than 90%. A broad-spectrum antibiotic, levofloxacin 500 mg in 100 mL of NS is ordered to be administered IV over 60 minutes once daily. a. After examining the physician orders, in what sequence should the nurse provide the care to the patient admitted to the hospital? Give the rationale for the sequence chosen. b. On what areas should the nurse focus the assessment to detect potential complications for Mr. Jones? c. Fundamentals of nursing
What patient education does Mr. Jones need from the nurse to help prevent the reoccurrence of an infection and to get treatment for an infection promptly? 2. The oncology clinical nurse specialist (CNS) is asked to develop a staff development program for registered nurses who will be administering chemotherapeutic agents. Because the nurses will be administering a variety of chemotherapeutic drugs to oncology patients, the CNS plans on presenting an overview of agents, classifications, and special precautions related to the safe handling and administration of these drugs. a. What does the CNS describe as the goals of chemotherapy? b. Fundamentals of nursing
How should the CNS respond to the following question: “Why do patients require rounds of chemotherapeutic drugs, including different drugs and varying intervals?” c. In teaching about the administration of chemotherapeutic agents, what signs of extravasation should the nurse include? d. What clinical manifestations of myelosuppression, secondary to chemotherapy administration, should the CNS include in this program? Case Study, Chapter 16, End-of-Life Care 1. Joe Clark, 79 years of age, is a male patient who is receiving hospice care for his terminal illnesses that include lung cancer and chronic obstructive pulmonary disease (COPD). He developed bilateral pleural effusion (fluid that accumulates in the pleural space of each lung), which has compromised his lung expansion. He states that he is short of breath and feels anxious that the next breath will be his last. The patient is admitted to the hospital for a thoracentesis (an invasive procedure used to drain the fluid from the pleural space so the lung can expand). The thoracentesis is being used as a palliative measure to relieve the discomfort he is experiencing. Low dose morphine is ordered to provide relief from dyspnea or discomfort. The patient is prescribed Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent (fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen ordered per nasal cannula as needed for comfort. a. What nursing measures should the nurse use to manage the patient’s dyspnea? b. The patient complains that he has no appetite and struggles to eat and breathe. What nursing measures should the nurse implement to manage this physiologic response to the terminal illnesses? 2. Ms. Williams underwent a lobectomy for lung cancer 6 months ago, followed by treatment with radiation therapy and chemotherapy. On her most recent visit to the oncologist, she is told that despite the treatments, there is evidence of metastatic disease in her spine. The physician explains that there are no further treatment options, and refers Ms. Rogers to Hospice for continuing care. a. What are the underlying principles of hospice? b. To be eligible for Medicare and Medicaid Hospice benefits, what information needs to be provided by Ms. Williams’ physician? c. Ms. Williams has severe back pain and is concerned whether the hospice will assist with her pain management. Case Study, Chapter 17, Preoperative Nursing Management 1. Joan Arnold, 67 years of age, is a female patient who underwent a coronary angiogram that diagnosed severe coronary artery disease in three of her coronary arteries, the left anterior descending, the left circumflex, and the right coronary artery. She is scheduled for a coronary artery bypass graft operation tomorrow. The nurse provides patient education for Mrs. Arnold and her husband, which includes watching a hospital video on the operation, the intensive care environment, what to expect after the surgery, the recovery period, and cardiac rehabilitation. The video also covered the importance of coughing and deep breathing, using an incentive spirometer, splinting, early ambulation, pain medication, and how to position oneself safely. The video stressed the importance of not rolling onto the side that the chest tube may be in place postoperatively. The video also discussed the preoperative preparation. Fundamentals of nursing
The nurse also provided a booklet on the subject material. The nurse had a session with the patient and her husband to assess their understanding and to answer any questions they may have had. a. What specific preoperative nursing measures should the nurse review with the patient to help decrease the risk for postoperative complications? b. Explain the role of the nurse when implementing the immediate preoperative preparation the day before surgery and the morning of the surgery. 2. The nurse in a gynecology clinic is completing preoperative teaching for a patient scheduled for an abdominal hysterectomy next week. The patient states that she is currently taking 325 mg of aspirin daily for chronic joint pain, along with a multivitamin. The patient has type 2 diabetes; she closely monitors her blood glucose levels. Currently, she is taking an oral hypoglycemic agent. The nurse advises her to ask the anesthesiologist whether she should take this medication the morning of surgery. a. The nurse instructs the patient to stop taking the aspirin. What is the rationale for this action? b. Why is it important to assess the patient for use of herbal products prior to surgery? c. The patient asks how surgery could affect her blood glucose; how should the nurse respond? Case Study, Chapter 18, Intraoperative Nursing Management 1. Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40 years. a. What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age? b. Explain the role of the nurse in providing patient safety measures during the intraoperative period. 2. Mr. Bond is a 32-year-old Caucasian man who plays professional football. He was admitted for repair of a rotator cuff injury sustained in a game. In excellent shape, Mr. Bond has a muscular build and his body fat is 18%. Mr. Bond is transferred to the operating room, and the anesthesiologist begins to administer general anesthesia. During the induction of anesthesia, Mr. Bond develops tachycardia and dysrhythmias. His condition continues to deteriorate and he becomes severely hypotensive and exhibits decreased cardiac output. The anesthesiologist states that Mr. Bond is developing malignant hyperthermia. a. What risk factor does Mr. Bond have for malignant hyperthermia? b. What clinical manifestations of malignant hyperthermia does Mr. Bond demonstrate? c. Based on the patient’s condition, the surgical procedure is stopped and 100% oxygen is started.
Additionally, a muscle relaxant and sodium bicarbonate are administered. What are the rationales for these medications? Case Study, Chapter 19, Postoperative Nursing Management 1. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. Fundamentals of nursing
The patient’s cardiac assessment is within normal limits.
\The patient is receiving O2 at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. a. Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed. b. What gerontological postoperative considerations should the nurse make? 2. Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. a. Explain the wound healing process according to the phase of Mr. Smith’s wound? b. The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain how to perform this dressing change. … Fundamentals of nursing