Med Surg 3 Final Exam
The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating
the patient about this disorder, which age-related cardiovascular change should the nurse include? ***
Reduced number of pacemaker cells in the SA node
Rationale: A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
The nurse is providing care to an older adult patient who is diagnosed with congestive heart failure
(CHF). When educating the patient about this disorder, which age-related cardiovascular change should
the nurse include? *** Increased size of the left atrium
Rationale: Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible
for an increased risk for hypertension and congestive heart failure (CHF).
The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When
educating the patient about this disorder, which age-related cardiovascular change should the nurse
include? *** Decreased cardiac responsiveness to beta-adrenergic stimuli
Rationale: Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
Which electrolyte imbalance should the nurse monitor an older adult patient for due to impaired renal
diluting capacity and concentrating ability? *** Hyponatremia
Rationale: Sodium imbalances occur due to impaired renal diluting capacity and concentrating ability.
Which clinical manifestation does the nurse anticipate when providing care to an older adult patient
diagnosed with failure to thrive (FTT)? *** Skin that loses elasticity with poor turgor
,Rationale: Dehydration, manifested with decreased elasticity and turgor of the skin, supports the
diagnosis of FTT.
The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome
(ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing
hypoxia as a result of the ARDS diagnosis? *** Dyspnea
Rationale: Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS.
The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms
of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am
having trouble breathing." Based on this data, which does the nurse suspect the patient is experiencing?
*** Acute respiratory distress syndrome
Rationale: Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The patient
has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse
should suspect the patient is developing acute respiratory
A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which
nursing diagnosis is a priority for this patient? *** Impaired Spontaneous Ventilation
Rationale: A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per minutes
and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues
without intervention, the patient could experience respiratory arrest.
A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation.
Which nursing action is appropriate for this patient? *** Place in the Fowler position
, Rationale: Weaning a patient from mechanical ventilation should begin in the morning when the patient
is well-rested. The patient should be in the Fowler or high-Fowler position, as this facilitates lung
expansion and reduces the work of breathing.
A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The
patient has suffered traumatic injury that may involve multiple body systems. Which is the priority
nursing assessment for this patient? *** Airway maintenance with cervical spine protection
When caring for the trauma victim the nurse must always prioritize assessments, with the ABCDEs as the
highest-priority concerns. It is imperative that the nurse's first concern is airway maintenance with
cervical spine protection.
The nurse caring for a patient admitted with septic shock is aware of the need to assess for the
development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would
indicate the development of ARDS? *** Tachypnea
Ratioanle: Dyspnea and tachypnea are early clinical manifestations of ARDS.
The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress
syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm
Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with
positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output
secondary to positive pressure ventilation? *** Urine output 25mL/hr
Rationale:Decreased cardiac output is supported by a decrease of urine output. Expected urine output is
at least 30 mL/hr. This patient's urine output is decreased; therefore, this finding supports the diagnosis
of decreased cardiac output.
A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory
distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this
patient? *** Mechanical ventilation
The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating
the patient about this disorder, which age-related cardiovascular change should the nurse include? ***
Reduced number of pacemaker cells in the SA node
Rationale: A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
The nurse is providing care to an older adult patient who is diagnosed with congestive heart failure
(CHF). When educating the patient about this disorder, which age-related cardiovascular change should
the nurse include? *** Increased size of the left atrium
Rationale: Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible
for an increased risk for hypertension and congestive heart failure (CHF).
The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When
educating the patient about this disorder, which age-related cardiovascular change should the nurse
include? *** Decreased cardiac responsiveness to beta-adrenergic stimuli
Rationale: Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
Which electrolyte imbalance should the nurse monitor an older adult patient for due to impaired renal
diluting capacity and concentrating ability? *** Hyponatremia
Rationale: Sodium imbalances occur due to impaired renal diluting capacity and concentrating ability.
Which clinical manifestation does the nurse anticipate when providing care to an older adult patient
diagnosed with failure to thrive (FTT)? *** Skin that loses elasticity with poor turgor
,Rationale: Dehydration, manifested with decreased elasticity and turgor of the skin, supports the
diagnosis of FTT.
The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome
(ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing
hypoxia as a result of the ARDS diagnosis? *** Dyspnea
Rationale: Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS.
The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms
of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am
having trouble breathing." Based on this data, which does the nurse suspect the patient is experiencing?
*** Acute respiratory distress syndrome
Rationale: Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The patient
has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse
should suspect the patient is developing acute respiratory
A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which
nursing diagnosis is a priority for this patient? *** Impaired Spontaneous Ventilation
Rationale: A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per minutes
and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues
without intervention, the patient could experience respiratory arrest.
A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation.
Which nursing action is appropriate for this patient? *** Place in the Fowler position
, Rationale: Weaning a patient from mechanical ventilation should begin in the morning when the patient
is well-rested. The patient should be in the Fowler or high-Fowler position, as this facilitates lung
expansion and reduces the work of breathing.
A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The
patient has suffered traumatic injury that may involve multiple body systems. Which is the priority
nursing assessment for this patient? *** Airway maintenance with cervical spine protection
When caring for the trauma victim the nurse must always prioritize assessments, with the ABCDEs as the
highest-priority concerns. It is imperative that the nurse's first concern is airway maintenance with
cervical spine protection.
The nurse caring for a patient admitted with septic shock is aware of the need to assess for the
development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would
indicate the development of ARDS? *** Tachypnea
Ratioanle: Dyspnea and tachypnea are early clinical manifestations of ARDS.
The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress
syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm
Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with
positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output
secondary to positive pressure ventilation? *** Urine output 25mL/hr
Rationale:Decreased cardiac output is supported by a decrease of urine output. Expected urine output is
at least 30 mL/hr. This patient's urine output is decreased; therefore, this finding supports the diagnosis
of decreased cardiac output.
A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory
distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this
patient? *** Mechanical ventilation
