Adult 2 Exam 2 Questions With Complete Solutions
A 78 year old client is admitted to the emergency department
with numbness and weakness of the left arm and slurred speech.
Which collaborative intervention is priority?
A. Prepare to administer recombinant tissue plasminogen
activator (rt-PA).
B. Schedule for A STAT computed tomography (CT) scan of
the head.
C. Notify the speech pathologist for an emergency consult.
D. Discuss the precipitating factors that caused the symptoms.
correct answers B. Schedule for A STAT computed tomography
(CT) scan of the head.
A client arrives in the emergency department with an ischemic
stroke and may be a candidate to receive tissue plasminogen
activator (t-PA) administration. Which is the priority nursing
assessment?
A. Upcoming surgical procedures.
B. Functional limitations.
C. Risk factors for stroke.
D. Time of onset of current stroke. correct answers D. Time of
onset of current stroke.
A patient admitted to the hospital with an exacerbation of
chronic heart failure tells the nurse, "I felt fine when I went to
bed, but I woke up in the middle of the night feeling like I was
suffocating!" The nurse can best document this assessment
information as:
,A. Two-pillow orthopnea.
B. Pulsus paradoxus
C. Paroxysmal nocturnal dyspnea.
D. Acute bilateral pleural effusion. correct answers C.
Paroxysmal nocturnal dyspnea.
A patient is diagnosed with left ventricular failure. Which
findings should the nurse recognize as being consistent with this
diagnosis? Select all that apply.
1. fatigue
2. substernal chest pain during exercise
3. 5 cm jugular vein distention at 30 degrees
4. bilateral inspiratory crackles to midscapulae
5. complaints of shortness of breath with minimal exertion
correct answers 1. fatigue
4. bilateral inspiratory crackles to midscapulae
5. complaints of shortness of breath with minimal exertion
A patient who is receiving digoxin daily has a serum potassium
level of 3 mEq/L and is complaining of anorexia. A digoxin
level is drawn and the nurse notes the digoxin level is out of
therapeutic range?
a. 1.0 ng/ml
b. 0.8ng/ml
c. 0.3 ng/ml
d. 0.5 ng/ml correct answers c. 0.3 ng/ml
, A patient who is receiving digoxin daily has a serum potassium
level of 3 mEq/L, and is complaining of anorexia. The physician
orders a digoxin serum level. Which of the following lab values
indicate the patient is NOT experiencing toxicity, and the level
is therapeutic?
a. 1.0 ng/mL
b. 2.4 ng/mL
c. 3.0 ng/mL
d. 0.4 ng/mL correct answers a. 1.0 ng/mL
therapeutic range: 0.8 ng/mL to 2.0 ng/mL except for those in
heart failure: 0.5 ng/mL to 0.8 ng/m
A patient with a stroke has progressive development of
neurologic deficits with increasing weakness and decreased
level of consciousness (LOC). The priority nursing diagnosis for
the patient is
A. risk for aspiration related to inability to protect airway.
B. risk for impaired skin integrity related to immobility.
C. disturbed sensory perception related to brain injury.
D. impaired physical mobility related to weakness correct
answers A. risk for aspiration related to inability to protect
airway.
A patient with heart failure suddenly develops extreme dyspnea,
tachycardia, and lung crackles. What are the priority
collaborative interventions? Select all that apply.
A 78 year old client is admitted to the emergency department
with numbness and weakness of the left arm and slurred speech.
Which collaborative intervention is priority?
A. Prepare to administer recombinant tissue plasminogen
activator (rt-PA).
B. Schedule for A STAT computed tomography (CT) scan of
the head.
C. Notify the speech pathologist for an emergency consult.
D. Discuss the precipitating factors that caused the symptoms.
correct answers B. Schedule for A STAT computed tomography
(CT) scan of the head.
A client arrives in the emergency department with an ischemic
stroke and may be a candidate to receive tissue plasminogen
activator (t-PA) administration. Which is the priority nursing
assessment?
A. Upcoming surgical procedures.
B. Functional limitations.
C. Risk factors for stroke.
D. Time of onset of current stroke. correct answers D. Time of
onset of current stroke.
A patient admitted to the hospital with an exacerbation of
chronic heart failure tells the nurse, "I felt fine when I went to
bed, but I woke up in the middle of the night feeling like I was
suffocating!" The nurse can best document this assessment
information as:
,A. Two-pillow orthopnea.
B. Pulsus paradoxus
C. Paroxysmal nocturnal dyspnea.
D. Acute bilateral pleural effusion. correct answers C.
Paroxysmal nocturnal dyspnea.
A patient is diagnosed with left ventricular failure. Which
findings should the nurse recognize as being consistent with this
diagnosis? Select all that apply.
1. fatigue
2. substernal chest pain during exercise
3. 5 cm jugular vein distention at 30 degrees
4. bilateral inspiratory crackles to midscapulae
5. complaints of shortness of breath with minimal exertion
correct answers 1. fatigue
4. bilateral inspiratory crackles to midscapulae
5. complaints of shortness of breath with minimal exertion
A patient who is receiving digoxin daily has a serum potassium
level of 3 mEq/L and is complaining of anorexia. A digoxin
level is drawn and the nurse notes the digoxin level is out of
therapeutic range?
a. 1.0 ng/ml
b. 0.8ng/ml
c. 0.3 ng/ml
d. 0.5 ng/ml correct answers c. 0.3 ng/ml
, A patient who is receiving digoxin daily has a serum potassium
level of 3 mEq/L, and is complaining of anorexia. The physician
orders a digoxin serum level. Which of the following lab values
indicate the patient is NOT experiencing toxicity, and the level
is therapeutic?
a. 1.0 ng/mL
b. 2.4 ng/mL
c. 3.0 ng/mL
d. 0.4 ng/mL correct answers a. 1.0 ng/mL
therapeutic range: 0.8 ng/mL to 2.0 ng/mL except for those in
heart failure: 0.5 ng/mL to 0.8 ng/m
A patient with a stroke has progressive development of
neurologic deficits with increasing weakness and decreased
level of consciousness (LOC). The priority nursing diagnosis for
the patient is
A. risk for aspiration related to inability to protect airway.
B. risk for impaired skin integrity related to immobility.
C. disturbed sensory perception related to brain injury.
D. impaired physical mobility related to weakness correct
answers A. risk for aspiration related to inability to protect
airway.
A patient with heart failure suddenly develops extreme dyspnea,
tachycardia, and lung crackles. What are the priority
collaborative interventions? Select all that apply.
