Exam 1 Flashcards
Which urine specific gravity would be expected in a patient admitted with dehydration?
1.030
A nurse is assessing a patient who has an acute respiratory infection that puts her at risk for hypoxemia. Which findings are early indicators?
Restlessness
Tachypnea
Confusion
Pallor
A nurse is assessing a patient who is having difficulty breathing. The patient is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following intervention is the nurse’s first priority?
Assist the patient to high fowler’s position
A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Patient and family teaching by the nurse should include which of the following instruction? (Select all that apply)
Check the position of the cannula frequently
Report any nasal stuffiness, nausea, or fatigue
Post “no smoking” signs in a prominent location
A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug?
hypokalemia
Oxygen is a therapeutic gas that treats
hypoxemia
True or false: Administering and adjusting oxygen levels requires a provider’s prescription
True
Which of the following are low-flow oxygen delivery systems?
nasal cannula
partial rebreather
Which of the following are manifestations of oxygen toxicity?
substernal pain
A nurse if providing tracheostomy care for her patient. In order to prevent infection and skin breakdown the nurse should provide tracheostomy care every
8 hours
The heart contains specialized areas of nerve tissue that initiate electrical impulses. Which of the following is considered the “pacemaker”?
SA node
You are caring for a patent with heart failure. All of the following statements are true about heart failure except:
does not lead to systemic and pulmonary edema impairing gas exchange
The heart valves that are the most commonly affected by structural abnormalities are:
mitral and aortic
True or false: anemia has an abnormally low level of red blood cells, hemoglobin,or both
true
What are examples of sensible fluid loss?
skin and lungs
Potassium, sodium, and calcium are examples of
cations
First symptom of volume loss is
thirst
A ph of
Acidosis
A pH of >7.45 is considered
alkalosis
a pH of 7.4 is considered
normal
A 63 –year-old man with emphysema says, “My doctor wants me to quit smoking. It’s too late now, though; I already have lung problems.” Which of the following would be the best response to his statement?
“Once you stop smoking, your body will begin to repair some of the damage to your lungs.”
Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions?
pneumonia
The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? (Select all that apply)
“Keep healthy snacks or gum available to chew instead of smoking a cigarette.”
“Plan a time to quit when you will not have many other demands or stressors in your life.”
“Reward yourself with an activity you enjoy when you quit smoking.”
Which of the following factors influence normal lung volumes and capacities? (Select all that apply)
activity level
body size
age
Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?
. Catecholamines
Which part of the ECG tracing represents ventricular depolarization?
t wave
Nursing interventions to reduce the risk of clot formation in the legs include which of the following activities?
Apply compression devices (sequential compression devices)
Turn the patient frequently or encourage frequent position changes
promote adequate hydration by encouraging oral intake
Your patient is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When interviewing her she tells you she is feeling more fatigue when walking upstairs and doing her normal activities. What normal physiologic changes in the cardiovascular system occur with aging? (Select all that apply)
Cardiac contractile strength is reduced
Heart valves become more rigid
Peripheral vessels lose elasticity
Troponin is a serum evaluation of contractile proteins that remain elevated for up to 7 days after a myocardial infarction
true
Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why?
Anions, because they carry a negative charge
Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?
active transport
Which of the following is the principal site for regulation of fluid and electrolyte balance?
renal system
Where sodium goes ____ goes
water
The nurse gathers the following data: BP=150/94Hg; neck veins distended; P-104 beats/min; pulse bounding; respiratory rate=20 breaths/min; T=98.6F. What disorder should the nurse suspect?
hypervolemia
The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to “shut up and act you age.” How should the nurse respond?
Calmly approach the child and tell him what is going to happen
The nurse assesses that her patient’s intravenous solution has infiltrated into the tissues. What action should the nurse take first?
Stop the infusion immediately
In a healthy adult, which of the following regulate(s) body fluids? (Select all that apply)
hormone levels
fluid intake
kidney function
Identify the mechanism(s) involved in acid-base balance. (Select all that apply)
buffer systems
renal mechanisms
respiratory mechanisms
Identify the appropriate intervention(s) for a patient with hypovolemia. (Select all that apply)
monitor I&O for at least every 8h
encourage fluid intake
monitor electrolyte lab values
Incentive spirometry measures the depth of
inspiration
During the simulation, Rosa DeLuca was 2 days post right hip surgery. Her surgical dressing was 48 hours old and had not been changed and as the nurse you noted red drainage. What is the proper procedure in the care of her wound dressing?
dd and secure 4X4 dressing material and call the surgeon
When putting electrodes on the chest for an ECG why does the gel on the electrode need to be moist versus dry?
A dry electrode will not conduct electrical activity
Of the following what contraindicates the placement of ECG leads on the skin of the chest?
leisons
as a lead clinical RN who can you delegate the task of doing an ECG?
another RN
Pale, cool, grayish skin; absence of a pulse; apnea; and pupil dilation may be signs of a
cardiac arrest
All of the following are the steps in providing CPR, which one is not?
When giving a breath (30 sec) making the chest rise and fall
True/False: the parasympathetic nervous system has no significant control over blood vessels
False
Cocaine has been linked to
endocarditis
aortic dissection
dysrhythmias
When caring for a patient who is on a continuous mechanical ventilator the bed should be raised to a level of 30-45 degrees to promote lung expansion, reduce gastric reflux, and prevent ventilator associated pneumonia. This position is called the
Semirecumbent position
When a patient is on a mechanical ventilator it is extremely important to prevent respiratory aspiration to prevent
pneumonia
Which procedure of care has been associated with preventing Ventilator-associated pneumonia (VAP)?
mouth care
A sac-like protrusion from a blood vessel or the heart, resulting from a weakening of the vessel wall or heart muscle is called an
aneurysm
What does ABCDE stand for?
A = asymmetry or shape B = Border irregularity C = Color variation within on lesion D = Diameter greater than 6 mm E = Evolving or changing in anyway
