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Quesitions, Interventions, INR

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1 Quesitions, Interventions, INR on Mon Nov 14, 2011 2:38 pm

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Guest
1. You have a patient diagnosed with lung cancer. What information regarding nutrition would you provide him? Select all that apply.
A. Encourage fluid intake to promote hydration.
B. Eat small, frequent meals.
C. Don't increase fluids.
D. Eat high-calorie foods to provide adequate nutrition.
A,B,D

2. A patient is admitted to the E.D. She is of African descent. She tells you that her pain is an 8 on a scale of 0-10. She also reports having a fever for the past 24 hours. Her O2 stats read 88% on 2L of O2 via nasal cannula. You suspect:
A. Iron defieiency anemia.
B. Pnuemonia.
C. Sickle Cell crisis
D. Hypoxia
C

3. You are teaching a group of adolescents about the risk factors of Melanoma skin cancer. You provide then with what infomration? Select all that apply.
A. You are high risk if you have blonde hair, blue eyes, fair skin, freckles.
B. You cannot get skin cancer if you have dark skin.
C. You are at increase risk of skin cancer if you sunbathe or go to tanning beds.
D. If you have a lot of moles.
A,B,D

4. You are taking care of a patient who had a lobectomy. She states that she doesn't know what she's going to do to care for herself when she leaves the hospital. The most therapeutic response is:
A. "Oh, you'll do fine!"
B. "That's what home health is for."
C. "What concerns you about returning home?"
D. "Can't your family stay with you until you recover?"
C

5. You understand that the nursing care for a patient post-op for removal of the breast on the left side are (select all that apply):
A. No Blood pressure or needle sticks on the right arm.
B. No blood pressure or needle sticks on the left arm.
C. Elevation of the affected side to promote drainage.
D. Elevation of the unaffected side to promote drainage.
B,C

My patient was admitted for small bowel obstruction. She was 24 years old. She had an ileostomy and a NG tube was placed. She was NPO b/c the doctor wanted to perform more tests to determine what was causing the SBO. She was fatigued.

Cellular:
Impaired Skin Integrity
I: Inspect wound daily/shift R:To monitor for any signs of infection
I: Consult a wound nurse as indicated R: to assist with developing plan of care for problematic or potentially serious wound.
I: Use appropriate wound/barrier dressings R: to protect the wound and surrounding areas

Perfusion:
Ineffective Gastrointestinal Perfusion
I: Auscultate bowel sounds R: hypoactive or absent bowel sounds may indicate perforation or bleeding.
I: Administer IV fluids and electrolytes R:To replace losses and maintain GI circulation
I: Administer analgesic as prescribed R: reduce pain, it can cause stress to the patient leading to more exacerbations.

INR of 4, the patient would be placed on Coumadin
I: Check VS, platelet counts, and PT
R: Monitor bleeding and clotting time
I: No green, leafy vegetables
R: They increase the risk of clotting
I: Observe for bleeding gums, bruising
R: These are indications of too much coumadin



2 Questions, Interventions, INR on Mon Nov 14, 2011 8:24 pm

Guest


Guest
I am not sure whether you had this pt before or after our simulation but it sounds like you are getting a lot of practice with SBO.

3 Re: Quesitions, Interventions, INR on Mon Nov 14, 2011 8:26 pm

Guest


Guest
hahahaha Stephanie, that is so true! Oh dear, I hope my next patient does start vomiting coffee grounds and giving me bloody stools! lol Very Happy

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