NURS E51 - PN2 Exam 1. Questions & Answers with Rationales. All 100% Correct.

Question 1 1 out of 1 points The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? Selected Answer: a. Decreased level of consciousness Answers: a. Decreased level of consciousness b. Increased skin tenting and dry mouth c. Development of ankle or sacral edema d. Postural hypotension and tachycardia Response Feedback: Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.  Question 2 1 out of 1 points A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? Selected Answer: d. Piperacillin/tazobactam (Zosyn) Answers: a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn) Response Feedback: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.  Question 3 1 out of 1 points A patient has been hospitalized with tuberculosis (TB). The patient’s spouse is fearful of entering the room where the patient is in isolation and refuses to visit. What action by the nurse is best? Selected Answer: b. Show the spouse how to follow the isolation precautions to avoid illness. Answers: a. Inform the spouse that the precautions are meant to keep other patients safe. b. Show the spouse how to follow the isolation precautions to avoid illness. c. Ask the spouse to explain the fear of visiting in further detail. d. Tell the spouse that he or she has already been exposed, so it’s safe to visit. Response Feedback: The nurse needs to obtain further information about the spouse’s specific fears so they can be addressed. This