Unfolding Case Study Dissection

Every question here, with the answer

1. Mrs. Jenson arrives with worsening shortness of breath, bilateral crackles, a respiratory rate of 27 breaths/minute, oxygen saturation of 88 percent on room air, and joint pain rated 6/10. Which nursing priority best reflects the clinical decision-making described in the case?

   1. Address the joint pain first because it is interfering with ADLs.
   2. Implement interventions to stabilize respiratory status before addressing pain.
   3. Delay interventions until the 12-lead ECG results are available.
   4. Focus first on the occupational therapy referral for limited shoulder range of motion.

   Answer: Implement interventions to stabilize respiratory status before addressing pain.

   The section identifies low oxygen saturation and elevated respiratory rate as the most concerning findings. Pain was important, but the nurse addressed it later after stabilizing respiratory status.

2. During the initial assessment, which findings are important cues the nurse should recognize when analyzing Mrs. Jenson’s situation? Select all that apply.

   1. Current medications because they can provide more information about the situation
   2. Shallow breaths and bilateral crackles in the lung bases
   3. Worsening shortness of breath, fatigue, and swelling in the lower extremities
   4. No significant family history reported
   5. Past medical history that may be relevant to the symptoms

   Answer: Current medications because they can provide more information about the situation, Shallow breaths and bilateral crackles in the lung bases, Worsening shortness of breath, fatigue, and swelling in the lower extremities, Past medical history that may be relevant to the symptoms

   The section describes the chief complaints, relevant past medical history, current medications, shallow breathing, and bilateral crackles as important assessment cues. The family history is documented as having no significant findings, but it is not identified as an important cue driving the nurse’s clinical decisions.

3. After oxygen is applied by nasal cannula, which assessment findings support that this nursing action was effective? Select all that apply.

   1. Respiratory rate improved slightly
   2. Oxygen saturation increased to 93 percent after oxygen was applied
   3. Temperature increased above baseline
   4. Heart rate improved slightly
   5. Blood pressure improved slightly

   Answer: Respiratory rate improved slightly, Oxygen saturation increased to 93 percent after oxygen was applied, Heart rate improved slightly, Blood pressure improved slightly

   The nurse evaluated oxygen therapy by reassessing vital signs. Improved oxygen saturation, heart rate, blood pressure, and respiratory rate supported that supplemental oxygen was effective; an increased temperature is not described as evidence of effectiveness.

4. The nurse finds an open wound on the bottom of Mrs. Jenson’s left foot with purulent drainage. The patient says it does not hurt and assumed it had healed. Which nursing response best reflects the application of care described in the case?

   1. Counsel the patient about maintaining skin integrity, especially on the feet, and involve diabetes education.
   2. Explain that absence of pain means the wound is healing as expected.
   3. Focus only on the sacral redness because the foot wound is painless.
   4. Wait to report the wound until the patient develops foot pain.

   Answer: Counsel the patient about maintaining skin integrity, especially on the feet, and involve diabetes education.

   The section connects diabetes and peripheral neuropathy with impaired skin healing and decreased pain sensation in the lower extremities. The nurse counseled the patient about skin integrity, especially foot care, and referred her to a diabetes educator for additional resources.

5. Mrs. Jenson asks for help walking to the bathroom but is unable to void after receiving IV furosemide earlier. Which nursing considerations or actions are consistent with the case discussion? Select all that apply.

   1. Recognize concern because the patient has not voided in more than six hours after receiving an IV diuretic
   2. Consider embarrassment as a possible contributing factor to being unable to void
   3. Perform a bladder scan to assess urine in the bladder
   4. Avoid assisting with toileting because urinary elimination is personal
   5. Anticipate that the provider may order straight catheterization if significant urine is present

   Answer: Recognize concern because the patient has not voided in more than six hours after receiving an IV diuretic, Consider embarrassment as a possible contributing factor to being unable to void, Perform a bladder scan to assess urine in the bladder, Anticipate that the provider may order straight catheterization if significant urine is present

   The nurse became concerned about no voiding for more than six hours after an IV diuretic, considered embarrassment, performed a bladder scan, and anticipated straight catheterization when significant urine was present. The section emphasizes comfort and support, not avoiding assistance.

6. Later in the shift, Mrs. Jenson reports new 7/10 lower back pain that is worse with immobility and improves slightly with ambulation. What is the best nursing action based on the case discussion?

   1. Encourage complete bed rest because ambulation changes the pain.
   2. Revise the plan of care by performing a focused pain assessment and reporting findings to the provider.
   3. Address only the earlier joint pain because it was present on admission.
   4. Assume the pain is expected because the patient is in a hospital bed.

   Answer: Revise the plan of care by performing a focused pain assessment and reporting findings to the provider.

   New onset back pain required the nurse to revise the plan of care. The nurse performed a focused pain assessment and reported findings, leading to medication and physical therapy orders.