Power Point Questions Flashcards
A patient with metabolic alkalosis has an SpO2 of 93% and a shift to the left in the oxygen-hemoglobin dissociation curve. Which action by the nurse is appropriate?
A. Administer supplemental oxygen because oxygen is not readily released to the tissues
A patients ABG results include the following: pH:7.32, PaO2 84, PaCO2 49 and SaO2 84%. For what should the nurse assess the patient?
A: Tachypnea
tachypnea is a rapid respiratory rate and indicates respiratory distress
The nurse would interpret an induration of 5mm resulting for TB skin testing as a positive finding in which pt?
A: A pt who is HIV infected
What factors in J.B.’s history increase his risk for lung cancer?
A: Smoking exposure to chemicals on job site
What are some risk factors for pneumonia?
Age, limited mobility, chronic heart failure
A 56 yr old normally healthy pt at the clinic is dx with bacterial community-acquired pneumonia. Before treatment is prescribed, the nurse asks the pt about an allergy to:
A: Erythtomycin
The nurse is caring for a patient with pneumonia. If pleural effusion is developing, the nurse would expect which finding?
A: Localized decreased breath sounds
R: symptoms of pleural effusion include: diminished breath sounds, decreased movement of the chest on the affected side, dullness to percussion, dyspnea, cough, and sharp and no radiating chest pain that is worse on inhalation
What risk factors does S.C have for TB?
Homelessness, I-V drug use, resident of the shelter, poverty, HIV
What diagnostic test would you expect the HCP to order for S.C. (TB)
TB skin test, IGRA, chest x-ray, sputum culture and sensitivity, sputum for AFB
What treatment do you expect for S.B. (TB)
4 drug therapy, isoniazid, rifampin, pyrazinamide, and ethambutol
What risk factors does D.F. have for the development of pulmonary embolism?
Obesity, orthopedic surgery, immobility, dehydration, heart failure
What clinical manifestations of PE does D.F. demonstrate?
Chest pain, dyspnea, tachycardia, tachypnea, restlessness, crackles
What diagnostic tests would you expect to teach D.F. about (PE)?
Serum D-dimmer levels, spiral CT scan, chest x-ray, ECG, troponin, b-natriuretic peptide. If cannot have contrast media for spiral CT scan, then V/Q scan
What are the priority assessment for A.M. on his return from the OR (trache)?
Airway patency, lung sounds, need for suctioning, bleeding around newly formed trach, mechanical vent settings, neurological assessment
What emergency equipment should be available at bedside for trache?
Need to have tracheostomy setup at beside as well as a second trach tube, forceps. Oburator should be available in case of decannulation. suction equipment
24 hrs after a pt had a tracheostomy, the tube accidentally dislodged after a coughing episode. Which action should the nurse take first?
A: Grasp the retention sutures to spread the tracheostomy opening
How will you assess prior to removing the tracheostomy?
A: Close the stoma with tape and apply an occlusive dressing. Close dressing if it gets soiled or wet. Stoma should close within 4-5 days
A patient is receiving a drug that decreases afterload. To evaluate the patients repose to this drug, what is the most important for the nurse to assess?
Blood pressure
R: Afterload is affected by the size of the ventricle, wall tension, and arterial blood pressure
A patient arrives at an urgent care center after experiencing unrelenting substernal and epigastric pain and pressure for about 12 hrs. The nurse reviews lab results with the understanding that at this point in times, a MI would by indicated by peak levels of:
A. Troponin
Troponin is the biomarkers of choice in the dx of MI
Troponin levels peak at 10-24 hrs
A patient returns to the cardiac observation area following a cardiac catherization with coronary angiography. Which assessment would require immediate action by the nurse?
St-segment elevation develops on the ECG
ST elevation on ECG indicates myocardial ischemia or injury with partial or total occlusion of a coronary artery
The nurse determines that the pt has stage 2 HTN is when a patients average BP is
Greater than or equal to 160/100
While performing BP screening at a health fair, the nurse counsels which person as having the greatest risk for developing HTN?
A 56 yr old man whose father dies at age 62 from a stroke
A pts BP is not responded consistently to rx drugs for HTN. The first cause of this lack of responsiveness the nurse should?
The patient not adhering to therapy
The nurse takes BP at a health fair. The nurse identifies which person as most at risk for developing HTN?
A 52 yr old male who smokes and has a patent with HTN
The nurse determines that which blood pressure would meet the criteria for a dx of stage 1 HTN
Stage one HTN is blood pressure if 140-159/90-99
A patients bp has not responded to the prescribed drugs for HTN. Which of the following should the nurse assess first?
Patients adherence to drug therapy
Two risk factors for CAD that increase the workload of the heart and increase Myocardial demand are:
HTN and cigarette smoking
Which pt is most at risk for developing CAD?
A HTN pt who smoke cigerattes
The nurse determines that teaching about implementing dietary changes to decrease the risk of CAD has been effective when the pt says:
Most of my fat intake should be from olive oil or the oils in nuts
A patient is admitted to the coronary care unit following a cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the HCP admission orders, which order should the nurse question?
tPA 100 mg IV infused over 3 hr
The most significant factor in long-term survival of a pt with sudden cardiac death is:
Rapid institution of emergency services and procedures
The nurse is caring for a pt who survived a sudden cardiac death. What should the nurse include in the discharge instructions?
“Your family members should learn to perform CPR and practice these skills regularly”
A pt with a hx of CHF is hospitalized with severe dyspnea and a dry, hacking cough. Assessment findings include pitting edema in both ankles, BP 170/100, P: 92 and R: 28. Which statement, if made by the nurse, is most accurate:
“ The manifestations indicate impaired emptying of both the right and let ventricles, with decreased forward blood flow
A pt with L sided HF is rx oxygen at 4 L/min nasal cannula, furosemide (Lasix), spironolactone (Aladctone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the pts response to these drugs?
Auscultate lung sounds
The home care nurse visits a pt with CHF who is taking digoxin (Lanoxin) and furosemide (Lasix). The pt complains of nausea and vomiting. Which action os most appropriate for the nurse to take?
Notify the HCP immediately
The nurse is caring for a patient with aortic stenosis. For what should the nurse assess the pt?
Systolic murmur
A 19 yr old pt with rheumatic heart disease is admitted to the hospital with a recurrence of rheumatic fever. In planning care for the pt, which nursing dx should the nurse include?
Ineffective health management related to lack of knowledge about long-term prophylactic antibiotic therapy
Following an aortic aneurysm repair, the pt suddenly develops severe pain in the R lower extremity. The right pedal pulse is decreased and the R foot is cool and pale. Which complication should the nurse suspect?
Embolization or graft occlusion
A pt with PAD has marked peripheral neuropathy. An appropriate nursing dx for the pt is
Risk for injury related to decrease sensation
The nurse teaches a pt with peripheral arterial disease. The nurse determines that further teaching is needed if the pt makes which statement?
I should cut back on my walks i’d it causes pain in my legs
The nurse is caring got a patient who is admitted after a head injury. When would the nurse obtain most of the data related to this patients mental status?
During the nursing health history
The nurse is caring for a patient who has a spinothalamic tract lesion. Which assessment finding would the nurse expect?
Loss of peripheral sensitivity to pain
How should the nurse assess cranial nerves III, IV, and VI?
Test the pts eye movements
The nurse is caring for a pt after a head injury. how should the nurse position the pt in the bed?
Side-lying with the head elevated 30 degrees
A patient with a head injury has an arterial BP of 92/50 and ICP of 18. The nurse uses the assessments to calculate the CCP How should the nurse interpret the results?
The CPP is low, and the BP should be increased
A pt with increased ICP is positioned in a lateral position with the HOB elevated 30 degrees. The nurse evaluates a need for lowering the HOB when the pt experiences:
Decreasing LOC
As one of your clinical assignments, you are assisting an RN with a health screening at a health fair. Which individual is at greatest risk for experiencing a stroke?
A 52 yr old African American make with HTN who is 35 lbs overweight
Interferon B-1b (Betaseron) has been prescribes with relapsing remitting MS. Which statement, if made by the pt, indicates that additional teaching is needed?
I will reduce my sodium intake to prevent edema
Several years later you see MJ at your outpatient clinic with a cough and fever. It is obvious that his Parkinson’s disease has advanced. During your assessment of him, you would expect to find?
Drooling, stooped posture, tremors, and a propulsive gait
An appropriate nursing dx for MJ at this stage of advanced Parkinson’s disease is:
Fish for aspiration related to impaired swallowing
You are called to the patients room by he pr spouse when the pt experiences a seizure. Upon finding the pt in a clonic reaction, what do you think you should do first?
Tuen the patient to the side
An older pt is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the pt is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate?
The mental changes are most likely caused by the infection and most often reversible
A daughter of a pt with early familial AD asks how AD is different from forgetfulness. You describe early warning signs of AD, including:
Having no memory of preparing a meal and forgetting to serve of eat it
DB is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for his is to
Maintain familiar routines of sleep, meals, drug administration, and activities
A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the pt is monitoring for
Bradycardia with hypoxemia
A young adult is hospitalized after an accident that resulted in a complete tan section of the spinal cord at the level of C7. The nurse informs the pr that after rehab, the level of function that is most likely to occur is the ability to
Drive a vehicle with hand controls
During assessment of the pt with a spinal cord injury at the level of T2 at the rehab center, which finding would concern the nurse the most
Marked perspiration on the pts face and arms
The nurse identifies that the patient with the greatest risk for UTI is
A 72 yr old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence
