BrilliantNurse.com questions and
answers
The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bro
nchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects t
o 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 - CORRECT ANSWER-
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 epi
gastric pain, the nurse expects to note which assessment finding?
1. Melena
2. Nausea
3. Hernia
4. Hyperthermia - CORRECT ANSWER-1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry fec
es. 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 Diseas
e. 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." - CORRECT ANSWER-
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 re
commended 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 asse
ssing lab results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110 beats pe
r minute, and the patient reports epigastricKpain. 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 - CORRECT ANSWER-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 replacem
ent 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 pla
telet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and sh
ould 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 - CORRECT ANSWER-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