EXAM 2 CHAPTER QUESTIONS AND ANSWERS.

EXAM 2 CHAPTER QUESTIONS AND
ANSWERS


The nurse is caring for an 80-year old client with progressive fatigue, shortness of
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breath, and headaches. What assessment question will the nurse ask? Select all that
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apply. - ANSWER: "What medications do you routinely take?"
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"Could you tell me about your dietary habits?"
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The nurse is caring for a client with bleeding gums that reports increased fever,
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fatigue, malaise, and "chills." What is the priority nursing intervention? - ANSWER:
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Review laboratory data and prepare to obtain blood cultures
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A client is being transitioned from IV heparin to oral warfarin. Which laboratory finding
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does the nurse identify confirming that warfarin treatment is effective? - ANSWER:
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International normalized ratio (INR) of 2.5
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The nurse understands that patients with which dysrhythmia constitute the largest
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group of those hospitalized with dysrhythmias? - ANSWER: Atrial fibrillation
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On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained
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ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with
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no reports of chest pain, but expresses feeling slightly short of breath. His blood
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pressure is 108/70. What is the nurse's first action? - ANSWER: Administration of IV
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amiodarone (Cordarone) and dextrose
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A client admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF) tells
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the nurse, "I feel fine, there's nothing wrong with me." Which nursing response is
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appropriate? - ANSWER: "AF can cause clots to form from irregular blood flow in the
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heart."
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Identify appropriate interventions for a patient experiencing inadequate oxygenation
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and tissue perfusion as a result of coronary artery disease. (Select all that apply.) -
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ANSWER: Notify the physician
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Maintain or initiate an IV line vv vv vv vv vv




Apply oxygen via nasal cannulavv vv vv vv




Administer nitroglycerin sublingually vv vv

, A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse
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asks what type of damage has been caused by the "heart attack." What is the
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appropriate nursing response? - ANSWER: "A heart attack evolves over several
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hours. We won't know the extent of the damage immediately."
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You are contributing to the assessment of a client with chest pain. Which symptoms
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would be most indicative of an myocardia infarction (MI)? Select all that apply. -
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ANSWER: Chest pain associated with ECG changes
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Chest pain relieved only by opioids
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Chest pain associated with shortness of breath
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A 48-year old female asks about her chance of developing an MI. You discuss risk
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factors with her. Which modifiable risk factors will you assess to guide the client's
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teaching plan? Select all that apply. - ANSWER: Smoking
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Obesity

Diet

A patient is being discharged to home on warfarin (Coumadin) therapy to manage an
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acute pulmonary embolism. Which patient response indicates a need for further
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teaching by the nurse? - ANSWER: "I should eat more green leafy vegetables like
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spinach."
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The nurse understands that which of the following is the most common manifestation
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of pneumonia in the older adult patient? - ANSWER: Confusion
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When performing a medication reconciliation for a newly admitted client before
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planned abdominal surgery, the nurse notes that the client is prescribed salmeterol
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and fluticasone daily for asthma control. What is the priority action for the nurse to
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take regarding this information to prevent harm? - ANSWER: Collaborate with the
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surgeon to arrange for continuation of this therapy in the perioperative period.
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A client with COPD has just been reclassified for disease severity from a GOLD 2 to a
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GOLD 3. Which client statement about changes in management or lifestyle indicate to
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the nurse that more teaching is needed to prevent harm? - ANSWER: "Now I will try
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to rest as much as possible and avoid any unnecessary exercise."
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Which statement about the genetics of cystic fibrosis is true? - ANSWER: Recessive
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disorder affecting chloride transport
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