Exam
Exam Solution zm
Chapter 7 Prioritization Delegation and Assignment 20 zm zm zm zm zm zm
26 A+ GRADE ASSURED COMPLETE SOLUTIONS AND VE
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RIFIED ANSWERS (6769A) zm zm
QUESTION 1 zm
Which finding in a client with aortic stenosis will be *most* important for the nurse t
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o report to the health care provider? •Temperature of 102.1°F (38.9°
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C) •Loud systolic murmur over sternum •Blood pressure of 110/88 mm Hg •Weak rad
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ial and pedal pulses to palpation
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ANSWER
•Temperature of 102.1°F (38.9° zm zm zm
C) •Because endocarditis is a concern with valvular disease, an elevated temperature indicates a nee
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d for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systo
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lic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic ste
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nosis and do not indicate an immediate need for further evaluation or treatment.
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QUESTION 2 zm
A client who has just arrived in the emergency department reports substernal and left
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arm discomfort that has been going on for about 3 hours. Which laboratory test will
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be *most* useful in determining whether the nurse should anticipate implementing th
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e acute coronary syndrome standard protocol? •Creatine kinase MB level •Troponin I
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level •Myoglobin level •C-reactive protein level
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ANSWER
•Troponin I level •Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarcti
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on (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglo
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bin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myo
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globin is nonspecific. Elevated C-
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reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting ac
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ute injury or infarction.
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QUESTION 3 zm
, When the nurse is monitoring a 53-year-
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old client who is undergoing a treadmill stress test, which finding will require the *m
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ost* immediate action? •Blood pressure of 152/88 mm Hg •Heart rate of 134 beats/m
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in •Oxygen saturation of 91% •Chest pain level of 3 (on a scale of 0 to 10)
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ANSWER
•Chest pain level of 3 (on a scale of 0 to 10) •Chest pain in a client undergoing a stress test indicat
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es myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or
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infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen satu
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ration are a normal response to exercise and are expected during stress testing.
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QUESTION 4 zm
The nurse makes a home visit to evaluate a hypertensive client who has been taking
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enalapril. Which finding is *most* important to report to the health care provider? •Cl
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ient reports frequent urination •Client's blood pressure is 138/86 mm Hg •Client com
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plains about a frequent dry cough •Client says, "I get dizzy sometimes if I stand up fas
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t."
ANSWER
•Client complains about a frequent dry cough •A persistent and irritating cough (caused by accumul
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ation of bradykinin) is a possible adverse effect of angiotensin-
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converting enzyme inhibitors such as enalapril and is a common reason for changing to another me
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dication category such as the angiotensin II receptor blockers. The other assessment data indicate a
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need for more client teaching and ongoing monitoring but would not require a change in therapy.
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QUESTION 5 zm
The emergency department nurse is caring for a client who was just admitted with lef
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t anterior chest pain, possible acute myocardial infarction (MI). Which action will the
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nurse take *first*? •Insert an IV catheter •Auscultate heart sounds •Administer subling
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ual nitroglycerin •Draw blood for troponin I measurement
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ANSWER
•Administer sublingual nitroglycerin •The priority for a client with unstable angina or MI is treatme
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nt of pain. It is important to remember to assess vital signs before administering sublingual nitrogly
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cerin. The other activities also should be accomplished rapidly but are not as high a priority.
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QUESTION 6 zm
The nurse is caring for a hospitalized client with heart failure who is receiving captop
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ril and spironolactone. Which laboratory value will be *most* important to monitor? •
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Sodium level •Blood glucose level •Potassium level •Alkaline phosphatase level
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ANSWER
Exam Solution zm
Chapter 7 Prioritization Delegation and Assignment 20 zm zm zm zm zm zm
26 A+ GRADE ASSURED COMPLETE SOLUTIONS AND VE
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RIFIED ANSWERS (6769A) zm zm
QUESTION 1 zm
Which finding in a client with aortic stenosis will be *most* important for the nurse t
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o report to the health care provider? •Temperature of 102.1°F (38.9°
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C) •Loud systolic murmur over sternum •Blood pressure of 110/88 mm Hg •Weak rad
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ial and pedal pulses to palpation
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ANSWER
•Temperature of 102.1°F (38.9° zm zm zm
C) •Because endocarditis is a concern with valvular disease, an elevated temperature indicates a nee
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d for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systo
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lic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic ste
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nosis and do not indicate an immediate need for further evaluation or treatment.
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QUESTION 2 zm
A client who has just arrived in the emergency department reports substernal and left
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arm discomfort that has been going on for about 3 hours. Which laboratory test will
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be *most* useful in determining whether the nurse should anticipate implementing th
zm zm zm zm zm zm zm zm zm zm zm
e acute coronary syndrome standard protocol? •Creatine kinase MB level •Troponin I
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level •Myoglobin level •C-reactive protein level
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ANSWER
•Troponin I level •Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarcti
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on (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglo
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bin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myo
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globin is nonspecific. Elevated C-
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reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting ac
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ute injury or infarction.
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QUESTION 3 zm
, When the nurse is monitoring a 53-year-
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old client who is undergoing a treadmill stress test, which finding will require the *m
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ost* immediate action? •Blood pressure of 152/88 mm Hg •Heart rate of 134 beats/m
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in •Oxygen saturation of 91% •Chest pain level of 3 (on a scale of 0 to 10)
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ANSWER
•Chest pain level of 3 (on a scale of 0 to 10) •Chest pain in a client undergoing a stress test indicat
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es myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or
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infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen satu
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ration are a normal response to exercise and are expected during stress testing.
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QUESTION 4 zm
The nurse makes a home visit to evaluate a hypertensive client who has been taking
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enalapril. Which finding is *most* important to report to the health care provider? •Cl
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ient reports frequent urination •Client's blood pressure is 138/86 mm Hg •Client com
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plains about a frequent dry cough •Client says, "I get dizzy sometimes if I stand up fas
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t."
ANSWER
•Client complains about a frequent dry cough •A persistent and irritating cough (caused by accumul
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ation of bradykinin) is a possible adverse effect of angiotensin-
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converting enzyme inhibitors such as enalapril and is a common reason for changing to another me
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
dication category such as the angiotensin II receptor blockers. The other assessment data indicate a
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
need for more client teaching and ongoing monitoring but would not require a change in therapy.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 5 zm
The emergency department nurse is caring for a client who was just admitted with lef
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t anterior chest pain, possible acute myocardial infarction (MI). Which action will the
zm zm zm zm zm zm zm zm zm zm zm zm zm
nurse take *first*? •Insert an IV catheter •Auscultate heart sounds •Administer subling
zm zm zm zm zm zm zm zm zm zm zm
ual nitroglycerin •Draw blood for troponin I measurement
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ANSWER
•Administer sublingual nitroglycerin •The priority for a client with unstable angina or MI is treatme
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
nt of pain. It is important to remember to assess vital signs before administering sublingual nitrogly
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cerin. The other activities also should be accomplished rapidly but are not as high a priority.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 6 zm
The nurse is caring for a hospitalized client with heart failure who is receiving captop
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ril and spironolactone. Which laboratory value will be *most* important to monitor? •
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Sodium level •Blood glucose level •Potassium level •Alkaline phosphatase level
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ANSWER
