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NUR 417 Exam 1 Self-Assessment Questions and Answers with
100% Complete Solutions UPDATED!!!
Mr E.F. has been admitted with complaints of shortness of
breath. The nurse knows that a full respiratory assessment is
necessary. She proceeds with which of the following
assessments? (select all that apply).
a. observing for dyspnea
b. taking the patients temperature
c. counting the respiratory rate
d. obtaining an oxygen saturation
e. auscultating the lungs - ANSWER a. observing for dyspnea
c. counting the respiratory rate
d. obtaining an oxygen saturation
e. auscultating the lungs
To assess Mr. E.F.'s complaint of shortness of breath thoroughly,
the nurse should perform which of the following assessments?
(Select all that apply).
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a. Observing for dyspnea: This is important to note the
presence and severity of any difficulty in breathing.
c. Counting the respiratory rate: Assessing the respiratory rate
can provide crucial information about the patient's breathing
pattern and effort.
d. Obtaining an oxygen saturation (SpO2) reading: This
measures the amount of oxygen in the blood and is essential in
evaluating oxygenation status.
e. Auscultating the lungs: Listening to the lung sounds can
reveal any abnormalities such as crackles, wheezes, or
decreased breath sounds. - ANSWER All of the above
Upon further assessment, you find that the client is a 68 year
old male with a past medical history (PMHX) of type 2 DM, HTN,
hyperlipidemia, and CAD. He has had two MIs in the past. His
height is 5'9" and his weight is 270 lb. He is a 30-pack year
smoker.
Based on all of these findings, what medical diagnosis could you
anticipate is the cause of the patient's shortness of breath?
_________________________ - ANSWER heart failure
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The client tells you that he is having difficulty breathing at night
but does not notice any swelling in his feet. Based on this, what
type of heart failure do you anticipate the patient is
experiencing?
_____________________________________ - ANSWER left-
sided heart failure
In left-sided heart failure (specifically HFpEF), the heart's left
ventricle has difficulty relaxing and filling with blood properly
during diastole (when the heart relaxes and fills with blood).
This can lead to increased pressure in the left atrium and
subsequently in the pulmonary veins, causing fluid to leak into
the lungs. This fluid accumulation in the lungs leads to
symptoms such as difficulty breathing, especially noticeable
when lying down (orthopnea) or during the night (paroxysmal
nocturnal dyspnea).
The absence of noticeable swelling in the feet (typically
indicative of right-sided heart failure) suggests that the fluid
accumulation and congestion are primarily occurring in the
lungs (pulmonary congestion) rather than in the peripheral
tissues.
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NUR 417 Exam 1 Self-Assessment Questions and Answers with
100% Complete Solutions UPDATED!!!
Mr E.F. has been admitted with complaints of shortness of
breath. The nurse knows that a full respiratory assessment is
necessary. She proceeds with which of the following
assessments? (select all that apply).
a. observing for dyspnea
b. taking the patients temperature
c. counting the respiratory rate
d. obtaining an oxygen saturation
e. auscultating the lungs - ANSWER a. observing for dyspnea
c. counting the respiratory rate
d. obtaining an oxygen saturation
e. auscultating the lungs
To assess Mr. E.F.'s complaint of shortness of breath thoroughly,
the nurse should perform which of the following assessments?
(Select all that apply).
1|Page
,2|Page
a. Observing for dyspnea: This is important to note the
presence and severity of any difficulty in breathing.
c. Counting the respiratory rate: Assessing the respiratory rate
can provide crucial information about the patient's breathing
pattern and effort.
d. Obtaining an oxygen saturation (SpO2) reading: This
measures the amount of oxygen in the blood and is essential in
evaluating oxygenation status.
e. Auscultating the lungs: Listening to the lung sounds can
reveal any abnormalities such as crackles, wheezes, or
decreased breath sounds. - ANSWER All of the above
Upon further assessment, you find that the client is a 68 year
old male with a past medical history (PMHX) of type 2 DM, HTN,
hyperlipidemia, and CAD. He has had two MIs in the past. His
height is 5'9" and his weight is 270 lb. He is a 30-pack year
smoker.
Based on all of these findings, what medical diagnosis could you
anticipate is the cause of the patient's shortness of breath?
_________________________ - ANSWER heart failure
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, 3|Page
The client tells you that he is having difficulty breathing at night
but does not notice any swelling in his feet. Based on this, what
type of heart failure do you anticipate the patient is
experiencing?
_____________________________________ - ANSWER left-
sided heart failure
In left-sided heart failure (specifically HFpEF), the heart's left
ventricle has difficulty relaxing and filling with blood properly
during diastole (when the heart relaxes and fills with blood).
This can lead to increased pressure in the left atrium and
subsequently in the pulmonary veins, causing fluid to leak into
the lungs. This fluid accumulation in the lungs leads to
symptoms such as difficulty breathing, especially noticeable
when lying down (orthopnea) or during the night (paroxysmal
nocturnal dyspnea).
The absence of noticeable swelling in the feet (typically
indicative of right-sided heart failure) suggests that the fluid
accumulation and congestion are primarily occurring in the
lungs (pulmonary congestion) rather than in the peripheral
tissues.
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