the use of thrombolytics, anticoagulants, and/or surgery right away.

1. A 65-year-old female client is admitted to the hospital with chronic pain. The
client’s pain appeared to be well controlled on the I.V. morphine via a patient-
controlled analgesia (PCA) pump. When discharged 2 days ago, he was switched to
oral morphine. The client now reports 8/10 pain scale and wants the morphine via
PCA pump. Which of the following represents the most likely explanation for the
client’s reports of inadequate pain control?
A. I.V. morphine addiction.
Research suggests that clients do not become addicted to opioids when dosed
adequately.
B. I.V. opioid withdrawal.
There is no evidence to suggest that the client is having withdrawal symptoms.
C. Morphine physical dependency.
There is no evidence to suggest that the client is physically addicted.
D. Undermedicated on the oral opioid.
Most clients after being switched from I.V. administration to oral opioid and
report inadequate pain control have been undermedicated. Equianalgesic
conversions should be made to provide estimates of the equivalent dose needed
for the same level of relief as provided by the I.V. dose.

Test Taking Strategy:

Note the strategic word, most likely. Focus on the data in the question and
determine if the client is having opioid addiction, withdrawal, and physical
dependence. Since there is no enough data that could suggest opioid addiction,
withdrawal, and physical dependence, eliminate option 1, 2, and 3.

Intro:
Pain is an unpleasant physical and emotional sensation associated with tissue
damage. It enables the body to respond and avoid further tissue damage.

Pathophysiology:
When sensory nerve endings known as nociceptors (also known as pain
receptors) come into contact with a painful or noxious stimuli, pain is produced.
The resulting nerve impulse goes from the sensory nerve ending to the spinal
cord, where it is quickly diverted to the brain via spinal cord and brainstem
neuron tracts. The brain interprets the pain feeling and instantly initiates a
motor reaction to try to stop the action that is generating the pain.

Signs and Symptoms:

Restlessness Verbal reporting of pain Agitation Moaning Crying

Nursing Assessment:
 Monitor the client for signs and symptoms of pain. Identify the type and pattern
of pain. Identify the precipitating factor(s) for the pain.

Medical Diagnosis:
Chronic pain isn't normally identified until you've been in pain for three to six
months on a regular basis.

Nursing Diagnosis:
Chronic Pain

Medical Treatment:
For diseases or conditions that no longer respond to treatment, focuses on
caring interventions and symptom management rather than cure, and can be
required at any age depending on the condition and prognosis.

Nursing Actions:
Set realistic goals for pain management, and use functional outcome as a
measure of attaining the goal. Provide pain relief through measures such as
distraction, relaxation, massage, biofeedback, ice, heat, and stretching.
Administer pain medication as prescribed, and instruct the client in its use.
Opioid use should be avoided as much as possible. Over-the-counter
preparations such as acetaminophen, ibuprofen, lidocaine patches, and creams
may be prescribed. Evaluate the effects of pain-reducing measures.

Take Home Message:

Consider the history of the client and the current plan of care before creating a
conclusion.

2. A 26-year-old unmarried female is admitted to the medical-surgical unit with the

complaint of flank pain, burning micturition, urinary urgency, facial puffiness, and
fever. She has been diagnosed with cystitis. She is a swimmer and recently
returned from a swimming championship tournament. The nurse is evaluating the
nursing care plan for this client. Which intervention should be included in the
client’s care plan?
A. Start antibiotic therapy immediately.
Antibiotic therapy should be started as per the physician's order. A urine culture
should be done before initiating the therapy.
B. Allow use of caffeinated products such as coffee, tea, cola.
Caffeinated products increase urinary urgency and frequency, so they should be
strictly avoided.
C. Insert a foley catheter.
A urinary catheter increases the risk of infection, and it is only inserted if
required.
D. Obtain a urinary culture specimen as prescribed before initiating antibiotics.
Before administering prescribed antibiotics, obtain a urine specimen for culture
and sensitivity, if prescribed, to identify bacterial growth. This will help in
administering sensitive antibiotics.

Test Taking Strategy:

Look at the question and identify the intervention that most appropriately
answers the question. Always look for the complete, correct answer.

Intro:
Cystitis is an inflammation of the bladder from an infection, obstruction of the
urethra, or other irritants.

Pathophysiology:
The most common causative organisms are Escherichia coli and Enterobacter,
Pseudomonas, and Serratia species. Cystitis is more common in women because
women have a shorter urethra than men, and the urethra in the woman is
located close to the rectum. Sexually active and pregnant women are most
vulnerable to cystitis.

Signs and Symptoms:

Frequency and urgency Burning on urination Voiding in small amounts Inability
to void Incomplete emptying of the bladder Lower abdominal discomfort or back
discomfort; bladder spasms Cloudy, dark, foul-smelling urine Hematuria
Malaise, chills, fever WBC count greater than 11,000 mm3 (11.0Â 109/L) on
urinalysis

Nursing Assessment:
Assess changes in a urinary pattern such as frequency, urgency, or hesitancy.
Assess the patient’s knowledge about antimicrobials and preventive health care
measures. Assess the characteristics of the patient’s urine, such as the colour,
concentration, odour, volume, and cloudiness.

Medical Diagnosis:
UTI

Nursing Diagnosis:
Acute pain is related to infection within the urinary tract. Deficient knowledge is
related to a lack of information regarding predisposing factors and prevention of
the disease.

Medical Treatment:
Antibiotic therapy
 Nursing Actions:
Relieve pain. Antispasmodic agents may relieve bladder irritability, and
analgesics and application of heat help relieve pain and spasm. Fluids. The
nurse should encourage the patient to drink liberal amounts of fluids to promote
renal blood flow and to flush bacteria from the urinary tract. Voiding. Encourage
frequent voiding every 2 to 3 hours to empty the bladder completely because this
can significantly lower bacterial urine counts, reduce urinary stasis, and prevent
reinfection. Irritants. Avoid urinary irritants such as coffee, tea, colas, and
alcohol.

Take Home Message:

Use good perineal care, wiping front to back. Avoid bubble baths, tub baths, and
vaginal deodorants or sprays. Void every 2 to 3 hours. Wear cotton pants and
avoid wearing tight clothes or pantyhose with slacks. Avoid sitting in a wet
bathing suit for prolonged periods of time. If pregnant, void every 2 hours. If
menopausal, use estrogen vaginal creams to restore pH. Use water-soluble
lubricants for intercourse, especially after menopause. Void and drink a glass of
water after intercourse.

3. A 28-year-old female arrived at the trauma care center after spilling hot cooking oil
on her right arm and foot. Her vital signs indicate a blood pressure of 149/87
mmHg, heart rate of 89 beats/min, respiratory rate of 20 breaths/min, and O2
saturation of 93%. The client looks extremely anxious and worried. To maintain
adequate nutrition in the emergent phase of burns, the nurse should plan to take
which action?
A. Insert a feeding tube and initiate enteral feedings.
Enteral feedings can usually be initiated during the emergent phase at low rates
and increased to the goal rate over 24 to 48 hours.
B. Infuse total parenteral nutrition via a central catheter.
Parenteral nutrition increases the infection risk, does not help preserve
gastrointestinal function, and is not routinely used in burn patients.
C. Encourage an oral intake of at least 5000 kcal per day.
During the emergent phase, the patient will be unable to eat enough calories to
meet nutritional needs and may have a paralytic ileus that prevents adequate
nutrient absorption.
D. Administer multiple vitamins and minerals in the IV solution.
Vitamins and minerals may be administered during the emergent phase, but
these will not meet the patient's caloric needs.

Test Taking Strategy:

The initial nutritional support for major burns is provided through enteral feeds
only.
Intro:
Burn injury is the result of heat transfer from one site to another. Burns disrupt
the skin, which leads to increased fluid loss, infection; hypothermia; scarring;
compromised immunity; and changes in function, appearance, and body image.
Young children and the elderly continue to have increased morbidity and
mortality compared to other age groups with similar injuries. Inhalation injuries,
in addition to cutaneous burns, worsen the prognosis. The severity of each burn
is determined by multiple factors that, when assessed, help the burn team
estimate the likelihood that a patient will survive and plan for the care for each
patient.

Pathophysiology:
Local response. According to the Rule of Nines, Burns that do not exceed 20% of
TBSA produce a local response. Systemic response. The systemic response is
caused by releasing cytokines and other mediators into the systemic circulation.
The release of local mediators and changes in blood flow, tissue edema, and
infection can cause the progression of the burn injury.

Signs and Symptoms:

Hypovolemia: This is the immediate consequence of fluid loss and decreases
perfusion and oxygen delivery. Decreased cardiac output: Cardiac output
decreases before any significant change in blood volume are evident. Edema:
Edema forms rapidly after burn injury. Decreased circulating blood volume:
Circulating blood volume decreases dramatically during burn shock.
Hyponatremia: Hyponatremia is common during the first week of the acute
phase, as water shifts from the interstitial space to the vascular space.
Hyperkalemia: Immediately after burn injury, hyperkalemia results from
massive cell destruction. Hypothermia: Loss of skin results in an inability to
regulate body temperature.

Nursing Assessment:
Focus on the major priorities of any trauma patient. The burn wound is a
secondary consideration, although aseptic management of the burn wounds and
invasive lines continues. Assess circumstances surrounding the injury, time of
injury, burn mechanism, whether the burn occurred in a closed space, the
possibility of inhalation of noxious chemicals, and any related trauma. Monitor
vital signs frequently. Monitor respiratory status closely; and evaluate apical,
carotid, and femoral pulses particularly in areas of circumferential burn injury
to an extremity. Start cardiac monitoring if indicated, especially if the patient
has a history of cardiac or respiratory problems, or experienced an electrical
injury. Check peripheral pulses on burned extremities hourly; use Doppler as
needed. Monitor fluid intake (IV fluids) and output (urinary catheter) and
measure hourly. Note amount of urine obtained when the catheter is inserted
(indicates pre-burn renal function and fluid status). Obtain history, assess body
temperature, body weight, history of pre-burn weight, allergies, tetanus
immunization, past medical-surgical problems, current illnesses, and use of
medications. Arrange for patients with facial burns to be assessed for corneal
injury. Continue to assess the extent of the burn; assess the depth of the
wound, and identify areas of full and partial thickness injury. Assess neurologic
status: consciousness, psychological status, pain and anxiety levels, and
behavior. Assess patient’s and family’s understanding of injury and treatment.
Assess the patient’s support system and coping skills.

Medical Diagnosis:
Full-thickness burns

Nursing Diagnosis:
Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation,
and upper airway obstruction. Ineffective airway clearance related to edema and
effects of smoke inhalation. Fluid volume deficit related to increased capillary
permeability and evaporative losses from burn wound. Hypothermia related to
loss of skin microcirculation and open wounds. Anxiety related to fear and the
emotional impact of burn injury.

Medical Treatment:
Transport: The hospital and the physician are alerted that the patient is en route
to initiate life-saving measures immediately. Priorities: Initial priorities in the
emergency department remain airway, breathing, and circulation. Airway: 100%
humidified oxygen is administered, and the patient is encouraged to cough so
that secretions can be removed by coughing. Chemical burns: All clothing and
jewelry are removed, and chemical burns should be flushed. Intravenous access:
A large-bore (16 or 18 gauge) IV catheter is inserted in the non-burned area.
Gastrointestinal access: If the burn exceeds 20% to 25% TBSA, a nasogastric
tube is inserted and connected to low intermittent suction because patients with
large burns become nauseated. Clean beddings: Clean sheets are placed over
and under the patient to protect the burn wound from contamination, maintain
body temperature, and reduce pain caused by air currents passing over exposed
nerve endings. Fluid replacement therapy: The total volume and rate of IV fluid
replacement is gauged by the patient’s response and guided by the resuscitation
formula.

Nursing Actions:
Promoting Gas Exchange and Airway Clearance. Restoring Fluid and Electrolyte
Balance. Maintaining Normal Body Temperature. Minimizing Pain and Anxiety.
Monitoring and Managing Potential Complications. Monitor IV and oral fluid
 intake; use IV infusion pumps. Measure intake and output and daily weight.
Report changes (e.g., blood pressure, pulse rate) to a physician. Provide a clean
and safe environment; protect the patient from sources of cross-contamination
(e.g., visitors, other patients, staff, equipment). Closely scrutinize wound to
detect early signs of infection. Maintain adequate nutrition.

Take Home Message:

Wound care: The patient and the family are instructed to wash small clean, open
wounds daily with mild soap and water and to apply the prescribed topical agent
or dressing. Education: The patient and the family require careful written and
verbal instructions about pain management, nutrition, prevention of
complications, specific exercises, and the use of pressure garments and splints.
Follow-up care: Patients who receive care in a burn center usually return to the
burn clinic periodically for evaluation, modification of burn care instructions,
and planning for reconstructive surgery. Referral: Patients who return home
after a severe burn injury, those who cannot manage their own burn care, and
those with inadequate support systems need a referral for home care.

4. A 45-year-old female client is admitted to the hospital with pulmonary embolism.

Which assessment finding should the nurse report to the primary health care
provider (PHCP) before initiating thrombolytic therapy in a pulmonary embolism
client?
A. Adventitious breath sounds
Adventitious breath sounds, a temperature of 99.4°F (37.4°C), and a
respiratory rate of 30 breaths per minute may be present in a pulmonary
embolism patient, but they are not necessarily indications that should be
reported before thrombolytic therapy is started.
B. Blood pressure of 200/112 mm Hg
Because of the danger of cerebral hemorrhage, thrombolytic treatment is not
recommended in patients with severe uncontrolled hypertension. As a result,
before starting therapy, the nurse would inform the PHCP of the blood pressure
readings.
C. Respiratory rate of 30 breaths per minute
Adventitious breath sounds, a temperature of 99.4°F (37.4°C), and a
respiratory rate of 30 breaths per minute may be present in a pulmonary
embolism patient, but they are not necessarily indications that should be
reported before thrombolytic therapy is started.
D. The temperature of 37.4°C orally
Adventitious breath sounds, a temperature of 99.4°F (37.4°C), and a
respiratory rate of 30 breaths per minute may be present in a pulmonary
embolism patient, but they are not necessarily indications that should be
reported before thrombolytic therapy is started.
Test Taking Strategy
Focus on the subject: a contraindication to thrombolytic treatment.
Adventitious breath sounds, a temperature of 99.4°F (37.4°C), and a
respiratory rate of 28 breaths per minute may be present in a pulmonary
embolism patient, but they are not necessarily indications that should be
reported before thrombolytic therapy is started.

Intro
The obstruction of pulmonary arteries by thrombi that originate elsewhere,
most commonly in the major veins of the legs or pelvis, is known as pulmonary
embolism (PE).

Pathophysiology
When a blood clot (thrombus) becomes lodged in a pulmonary artery and limits
blood flow to the lung, it is known as pulmonary embolism (PE). Pulmonary
embolism is most commonly caused by a thrombus in the deep venous system
of the lower limbs; however, it can also occur in the pelvic, renal, or upper
extremity veins, as well as the right heart chambers (see the image below).
Large thrombi might lodge at the bifurcation of the main pulmonary artery or
the lobar branches after reaching the lung, causing hemodynamic compromise.

Signs and Symptoms

Restlessness and apprehension Sudden onset of dyspnea and chest pain
Cough, hemoptysis,

Nursing Assessment
Health history. The patient's medical history is examined to see if he or she has
ever had a heart attack or stroke. Family history. A family history of
cardiovascular illness may predispose the patient to Pulmonary Embolism.
Medication record. Certain drugs can make you more susceptible to Pulmonary
Embolism. Physical exam. Warmth, redness, and inflammation are assessed in
the extremities.

Medical Diagnosis
Pulmonary Embolism often results in death within one (1) hour of the
beginning of symptoms, therefore early detection and diagnosis are critical.
Chest x-ray. The chest x-ray is normally normal, however infiltrates,
atelectasis, diaphragm elevation on the afflicted side, or pleural effusion may
be seen. ECG. Sinus tachycardia, PR-interval depression, and nonspecific T-
wave alterations are common on the ECG. ABG analysis. ABG study may
reveal hypoxemia and hypocapnia; nevertheless, even in the presence of PE,
ABG results may be normal. Pulmonary angiogram. The arterial blockage can
be directly shown under fluoroscopy and the perfusion deficit can be accurately
assessed using a pulmonary angiography. V/Q scan. The V/Q scan assesses
the distinct regions of the lungs and allows for comparisons of ventilation and
perfusion percentages in each.

Nursing Diagnosis
Ineffective peripheral tissue perfusion Risk for shock Acute pain

Medical Treatment
Pulmonary Embolism is frequently a medical emergency, hence emergency
management is a top priority. Anticoagulant treatment is used to prevent blood
clots. Heparin and warfarin sodium have long been the mainstays of treatment
for acute DVT and PE. Thrombolytic therapy is a treatment that prevents blood
clots from forming Urokinase, streptokinase, and alteplase are used to treat
PE, especially in seriously ill patients.

Nursing Actions
If you notice evidence of emboli, call the PHCP right away. Administer oxygen
and other medications, as well as intravenous (IV) anticoagulant therapy if
necessary.

Take Home Message

Massive PE is a medical emergency that necessitates the use of thrombolytics,
anticoagulants, and/or surgery right away.