AHFIN
1. A patient presents with liver injury due to history of Tylenol abuse. On arrival the patient is
unconscious. After giving him 3 liters of IV fluids the nurse does an assessment. The findings
were bilateral 2+ pedal edema, BP 160/90, HR 115. What would be the priority assessment
the nurse should do next?
a. Assess the lung sounds.
2. After interventions, stopping fluids, and giving a small dose of Lasix the patient became a little
responsive. ABG lab results come back and are as follows: pH 7.28 PaCo2 38 PaO2 89 HCO3 17.
Is there a sign of acid base imbalance?
a. Yes, metabolic acidosis.
3. A COPD patient is admitted with hypoxemia due to VQ mismatch. The nurse is anticipating the
delivery system that is used to provide oxygen. What type of oxygen flow would you provide
for this client?
a. Low levels of oxygen either via nasal cannula or using a face mask at 24%-32% oxygen.
4. A trauma patient who has acute heart failure has not gotten out of bed and has not been using
the incentive spirometer has become very restless. Vital signs reveal signs of decreased cardiac
output (low BP, bradycardic, and a thready pulse). A chest x ray reveals pneumonia. What
would be the priority intervention for this patient?
a. Prepare them for intubation.
5. What medication prescribed for the patient above would you want to
clarify? a. Azithromycin due to the client’s heart condition.
6. The patient is found to have fluids in the lungs due to bronchiectasis (damage to the airways
making it difficult to clear mucus) and requires postural drainage 3x daily. What would be
some essential teaching for this patient regarding postural drainage?
a. It needs to occur prior to or 3 hours after meals, use of pillows to position client, give
bronchodilator (albuterol) before the procedure, percuss over a towel to ensure there is
no discomfort.
7. A patient presents to the ED with complaints of feeling fluttering of the heart. The MD orders
for this patient to be placed on telemetry. Looking at the strip, how would you calculate the
HR?
a. Count the QRS complexes and multiply by 10 (for a 6 sec strip).
8. The patient is diagnosed with Atrial Flutter. What are the clinical manifestations the
patient would present with?
a. CAD, HTN, mitral valve disorders, pulmonary embolism, chronic lung disease, cor
pulmonale, cardiomyopathy, hyperthyroidism, and the use of drugs such as
digoxin, quinidine, and epinephrine (pg 765).
9. Where on the body should the electrodes be placed for a 5 lead EKG?
a. White on upper right near mid clavicular line, black on upper left near mid clavicular
line, green on lower right between 6 th and 7th intercostal space, and red lower left
between 6th and 7th intercostal space, with the brown lead just right of the sternum at
4th intercostal space.
10. A patient comes in complaining of epigastric pain and lower back pain. On examination the
nurse palpates an abdominal pulsatile mass. Assessing the BP she hears a systolic bruit. What
would be the expected diagnosis?
a. Triple A or abdominal aortic aneurysm.
1. A patient presents with liver injury due to history of Tylenol abuse. On arrival the patient is
unconscious. After giving him 3 liters of IV fluids the nurse does an assessment. The findings
were bilateral 2+ pedal edema, BP 160/90, HR 115. What would be the priority assessment
the nurse should do next?
a. Assess the lung sounds.
2. After interventions, stopping fluids, and giving a small dose of Lasix the patient became a little
responsive. ABG lab results come back and are as follows: pH 7.28 PaCo2 38 PaO2 89 HCO3 17.
Is there a sign of acid base imbalance?
a. Yes, metabolic acidosis.
3. A COPD patient is admitted with hypoxemia due to VQ mismatch. The nurse is anticipating the
delivery system that is used to provide oxygen. What type of oxygen flow would you provide
for this client?
a. Low levels of oxygen either via nasal cannula or using a face mask at 24%-32% oxygen.
4. A trauma patient who has acute heart failure has not gotten out of bed and has not been using
the incentive spirometer has become very restless. Vital signs reveal signs of decreased cardiac
output (low BP, bradycardic, and a thready pulse). A chest x ray reveals pneumonia. What
would be the priority intervention for this patient?
a. Prepare them for intubation.
5. What medication prescribed for the patient above would you want to
clarify? a. Azithromycin due to the client’s heart condition.
6. The patient is found to have fluids in the lungs due to bronchiectasis (damage to the airways
making it difficult to clear mucus) and requires postural drainage 3x daily. What would be
some essential teaching for this patient regarding postural drainage?
a. It needs to occur prior to or 3 hours after meals, use of pillows to position client, give
bronchodilator (albuterol) before the procedure, percuss over a towel to ensure there is
no discomfort.
7. A patient presents to the ED with complaints of feeling fluttering of the heart. The MD orders
for this patient to be placed on telemetry. Looking at the strip, how would you calculate the
HR?
a. Count the QRS complexes and multiply by 10 (for a 6 sec strip).
8. The patient is diagnosed with Atrial Flutter. What are the clinical manifestations the
patient would present with?
a. CAD, HTN, mitral valve disorders, pulmonary embolism, chronic lung disease, cor
pulmonale, cardiomyopathy, hyperthyroidism, and the use of drugs such as
digoxin, quinidine, and epinephrine (pg 765).
9. Where on the body should the electrodes be placed for a 5 lead EKG?
a. White on upper right near mid clavicular line, black on upper left near mid clavicular
line, green on lower right between 6 th and 7th intercostal space, and red lower left
between 6th and 7th intercostal space, with the brown lead just right of the sternum at
4th intercostal space.
10. A patient comes in complaining of epigastric pain and lower back pain. On examination the
nurse palpates an abdominal pulsatile mass. Assessing the BP she hears a systolic bruit. What
would be the expected diagnosis?
a. Triple A or abdominal aortic aneurysm.
