Answers| 2026 Update| Verified|
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The nurse is taking the health history of a patient being treated for
Emphysema and Chronic Bronchitis. After being told the patient has been
smoking cigarettes for 30 years, the nurse expects to note which
assessment finding?
1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure - 1. Increase in Forced Vital Capacity
(FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full
exhalation. A patient with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD often presents with a 'barrel chest,' which is seen as a
widened chest cavity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen
levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased
risk for cardiac failure, this is a potential complication and not an
assessment finding. Incorrect.
The nurse is taking the health history of a 70-year-old patient being treated
for a Duodenal Ulcer. After being told the patient is complaining of epigastric
pain, the nurse expects to note which assessment finding?
1. Melena
,2. Nausea
3. Hernia
4. Hyperthermia - 1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which
presents as black, tarry feces. This is a common manifestation of Duodenal
Ulcers, since the Duodenum is further down the gastric anatomy.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't
indicate a Duodenal Ulcer. Incorrect.
3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another
abdominal structure. It is not associated with an Ulcer and is a condition, not
an assessment finding. Incorrect.
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a
Duodenal Ulcer. Incorrect
A nurse is providing discharge teaching for a patient with severe
Gastroesophogeal Reflux Disease. Which of these statements by the
patient indicates a need for more teaching?
1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
2. "I'm going to make sure to remain upright after meals and elevate my
head when I sleep"
3. "I won't be drinking tea or coffee or eating chocolate any more."
4. "I'm going to start trying to lose some weight." - 1. "I'm going to limit my
meals to 2-3 per day to reduce acid secretion."
CORRECT - Large meals increase the volume and pressure in the stomach
and delay gastric emptying. It's recommended instead to eat 4-6 small
meals a day.
,2. "I'm going to make sure to remain upright after meals and elevate my
head when I sleep"
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or eating chocolate any more."
Incorrect - This is a correct verbalization of health promotion for GERD.
4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
The nurse in the Emergency Room is treating a patient suspected to have a
Peptic Ulcer. On assessing lab results, the nurse finds that the patient's
blood pressure is 95/60, pulse is 110 beats per minute, and the patient
reports epigastric pain. What is the PRIORITY intervention?
1. Start a large-bore IV in the patient's arm
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered - 1. Start a large-
bore IV in the patient's arm
CORRECT - The nurse should suspect that the patient is haemorrhaging
and will need need a fluid replacement therapy, which requires a large bore
IV.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis and assessment of Peptic
Ulcer Disease, it is not the priority intervention.
3. Prepare to insert an NG Tube
Incorrect - While this intervention may be used in the later stages of Peptic
Ulcer Disease, it is not the first and priority intervention.
4. Administer intramuscular morphine sulphate as ordered
Incorrect - While this is an important intervention to manage pain, it is not the
priority intervention.
A female patient with atrial fibrillation has the following lab results:
Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and
, potassium of 2.7 mEq/L. Which result is critical and should be reported to
the physician immediately?
1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L - 1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a
more critical lab result.
2. Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for
atrial fibrillation
4. Potassium of 2.7 mEq/L
CORRECT - A potassium imbalance for a patient with a history of
dysrhythmia can be life-threatening and can lead to cardiac distress.
While receiving normal saline infusions to treat a GI bleed, the nurse notes
that the patient's lower legs have become edematous and auscultates
crackles in the lungs. What should the nurse do first?
1. Stop the saline infusion immediately
2. Notify Physician
3. Elevate the patient's legs
4. Continue the infusion, since these are normal findings - 1. Stop the saline
infusion immediately
CORRECT - the patient has a fluid volume overload as a result of overly
rapid fluid replacement. The nurse should stop the infusion and notify the
physician.
2. Notify Physician
This is not the first action the nurse should take.
3. Elevate the patient's legs