NR 324 Adult Health I week 3 Questions with Answers (Graded A+)

NR 324 Adult Health I week 3 Questions with Answers (Graded A+) The nurse notices that the patient’s blood pressure is 100/50. Which part of the clinical judgement model is the nurse performing? Analyzing a cue Prioritizing a hypothesis Recognizing a cue Generating a solution Using Clinical Judgement with Perfusion The nurse decides to raise the head of the bed before administering oxygen. Which part of the clinical judgement model is the nurse using? Analyzing a cue Recognizing a cue Generating a solution Prioritizing a hypothesis Using Clinical Judgement with Perfusion The nurse checks the patient’s blood pressure and heart rate after administering the antihypertensive medication. Which of the following steps of the clinical judgement model is used with this action? Prioritizing a hypothesis Analyzing a cue Evaluating outcomes Generating a solution Self-Check: Analysis - Matching the System Which of the following are cues can suggest reduced perfusion? Select all that apply. Confusion Reduced capillary refill Increased capillary refill Increased B-type natriuretic peptide Decreased urine output Decreased B-type natriuretic peptide Self-Check: Recognizing Cues - Perfusion NR 324 Adult Health I week 3 Questions with Answers Self-Check: Generating Hypothesis - Matching Cue to Problem Review the potential problems listed below. Match the sign or symptom the nurse should expect to find as a possible cue, and identify the scope of the perfusion defect. Self-Check: Prioritizing hypotheses - Perfusion Review the following examples and select the answers to the questions about each hypothesis of altered perfusion. Reflect: Perfusion Recognizing Cues – Perfusion Select the cues that are an immediate or urgent priority. Prioritizing Hypotheses – Perfusion You are caring for Julie who is experiencing shortness of breath. Her oxygen saturation is 87%. In addition, her blood pressure is 160/90 with a pulse 102. The lower lungs have coarse crackles, and the shortness of breath worsens when layingflat. She has 3+ pitting edema in the lower extremities. Labs show an elevated B-type natriuretic peptide (BNP) level, a potassium level of 3.5 (normal 3.5 to 4.5 meq/dl). Select from the following nursing diagnoses/hypothesis and drag the top three to the correct prioritized order. Prioritizing Hypotheses – Perfusion Julie is diagnosed with heart failure. You receive the following orders from the provider, prioritize them in the order that would treat the patient most effectively: 1. Oxygen at 12 L per simple facemask 2. Given furosemide 40mg intravenously now 3. Give potassium 20mEq by mouth now 4. Continuous oximetry 5. Monitor vital signs q4hours Evaluating Outcomes – Perfusion Julie has the following Nursing Diagnoses: Alteration in perfusion as evidenced by elevated B-Type Natriuretic Peptide Levels, blood pressure 160/96, pulse 105 Alteration in gas exchange as evidenced by oxygen saturation below 90%, complaints of shortness of breath, and basilar fine crackles in bilateral lower lung lobes. Nursing actions/interventions: ● Furosemide 40mg IV ● Elevated head of bed to 45 degrees ● Administer oxygen at 2 L/min by nasal cannula The nurse should recognize that which assessment findings show improved perfusion? Select all that apply. Blood pressure increased Intake greater than output Intake less than output Pulse rate decreased Pulse rate elevated Blood pressure decreased Weight loss Weight gain Recognizing Cues – Perfusion You are caring for Bill who is complaining of palpitations and fatigue. His oxygen saturation is 93%. His blood pressure is 115/65 with a pulse 144. His heart rate is irregularly irregular. He is short of breath with activity. He denies chest discomfort. Which cues are pertinent to developing a hypothesis? Select all that apply. Blood pressure of 115/65 Pulse of 144 Shortness of breath with activity Symptoms of palpitations and fatigue Irregularly irregular heart rate Oxygen saturation of 93% Prioritizing Hypotheses – Perfusion Based on the abnormal findings from Bill’s presentation and assessment, which hypothesis should the nurse select? Altered fluid volume excess Altered gas exchange Altered fluid volume deficit Altered tissue perfusion Knowledge deficit Analyzing Cues – Perfusion Bill’s electrocardiogram shows atrial fibrillation. His heart rate is rapid and irregularly irregular. Which factors related to his heart rate and rhythm contribute to altered tissue perfusion? Select all that apply. Low blood flow in ventricle causing potential clot formation Decreased cardiac output Low blood flow in atrium causing potential clot formation Reduced filling time during the cardiac cycle Increased filling time during the cardiac cycle Increased cardiac output Generating a Plan – Perfusion The nurse is reviewing provider orders for Bill. Match the rationale with the order. Basic ECG Interpretation Prepare: Basic ECG Interpretation P Waves What does the P wave on a rhythm strip represent? Muscle contraction of both atriums of the heart Electrical stimulation of both atriums of the heart Electrical stimulation of both ventricles of the heart Muscle contraction of both ventricles of the heart T Waves What does the T wave represent on an electrocardiogram or rhythm strip? Depolarization of the atria of the heart Depolarization of the ventricles of the heart Repolarization of the ventricles of the heart Repolarization of the atria of the heart QT Interval A client with a prolonged QT interval is at risk for which abnormal cardiac rhythm? Tachycardia Bradycardia Sudden death Bundle branch block Self-Check: Analyzing Cues – Electrical Flow Through the Heart Put the following anatomic landmarks in the order in which the electricity normally flows through them: 1. Sinoatrial node 2. Atrium 3. Atrioventricular node 4. Bundle of HIS 5. Ventricle Self-Check: Recognizing Cues – The Cardiac Cycle Identify the correct intervals for this cardiac cycle from the choices given. Self-Check: Recognizing Cues – ECG Terms Select the correct term and drag it next to the definition that best matches. Self-Check: Recognize Cues – Heart Rhythm Interpretation Match the following rhythms with the correct interpretation. Self-Check: Analyze Cues – Altered Mobility ST Elevation What does ST elevation in 3 or more leads on a 12-lead electrocardiogram (ECG) suggest? Ventricular arrythmia Heart cell death Heart cell ischemia Normal variation Reflect: Basic ECG Interpretation Recognizing Cues – Rhythm Strips A client in the triage area is having chest discomfort. The unlicensed assistive personnel (UAP) brings a rhythm strip to the nurse to look at. The nurse notices the heart rate is 90 beats per minute, there is a P wave for every QRS, and the PR interval is 0.12ms. What is your analysis of the rhythm strip? Heart block Ventricular arrythmia Atrial arrhythmia Asystole Normal sinus rhythm Recognizing Cues – 12 Lead Electrocardiogram The client with chest discomfort is brought back to a room for a 12-lead electrocardiogram (ECG). What is the primary reasonfor using this type of ECG? Check for a myocardial infarction with ST elevation