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Exam (elaborations)

NURS 401 Exam 1 – Questions With Verified Solutions

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NURS 401 Exam 1 – Questions With Verified Solutions

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NURS 401 Exam 1 – Questions With Verified
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Terms in this set (25)



The nurse is providing education to d. "We should take hormones for menopause to
help reduce cardiovascular risks for a decrease the risk for heart attack"
women's book club. Which statement Rationale: meds used in hormone therapy can cause
made by a participant indicates a an increased incidence of MI or stroke in women
need for further teaching?
a. "We are more likely to die from
cardiovascular disease than men"
b. "We need to walk or do other
exercise everyday for 30 minutes"
c. "We need to stay away from people
who smoke"
d. "We should take hormones for
menopause to decrease the risk for
heart attack"


A client is admitted to the telemetry c. Check the client's arterial insertion site
unit after a right-sided cardiac Rationale: Pts who have had a cardiac catheterization
catheterization. What is the nurse's should be restricted to short-term bedrest, and the
priority when caring for this client? insertion site extremity should be kept straight. The
a. Assess the intensity and quality of nurse should assess the site for bloody drainage or
the client's pain hematoma formation because complications with
b. Position the client in a sitting vascular closure devices are not common but can be
position to improve breathing very serious.
c. Check the client's arterial insertion
site
d. Apply oxygen at 2 L/min via nasal
cannula

, A middle-aged man is admitted to the 1. Assess all VS, specifically BP, and conduct a head
cardiac unit after reports of a severe to toe assessment. VS should be taken to continue
headache and flushing of the face. He observing the pt's condition (specifically HTN) and
is diagnosed with severe trended to determine if treatment and interventions
hypertension. The patient is alert and are working. During the physical assessment, you will
oriented. BP = 192/104, HR = 88. You specifically need to listen to the heart for the
are the RN assigned to his care. There presence or absence of murmurs or other abnormal
is an unlicensed nurse technician heart sounds and perform a basic neurological
working with you. assessment to determine the pt's baseline
1. What assessment data will you orientation.
perform upon his arrival to the unit? 2. Can delegate: hourly BP checks, with
why? understanding that you must follow all Nurse
2. The cardiologist prescribes IV fluids, Practice Acts related to appropriate delegation.
hourly BP checks, BP medication, and Communicate: task that is to be performed and the
oxygen at 2 L/min via nasal cannula. method by which it should be (manual vs automated).
What part of the patient's care will you Also clarify that you need the findings reported back
delegate to the unlicensed nurse to you hourly.
technician? What information will you Follow up hourly to obtain report of the vitals so you
communicate upon delegation? can make appropriate nursing decisions
3. What interventions will you 3. Safety precautions; if need for invasive diagnostic
implement to ensure this patient's testing, determine if there is iodine-based contrast
safety? media allergies; report dysrhythmias immediately;
4. The patient's wife is very concerned continually assess pt's report of pain, especially when
about her husband returning to work pt's report is descriptive of angina or MI; teach pt
as owner of a roofing company. What safety precautions regarding calling for assistance if
education will you provide the patient pt needs to ambulate to the bathroom b/c syncope
and his wife at this time? With what can be related to severe HTN
health care team members w 4. Teach methods for decreasing cardiovascular
disease risk such as control of HTN with meds,
moderate physical exercise, smoking cessation,
decrease psychological stressors, and diet
modification.
Collaborate with dietician for nutrition planning,
primary care provider for meds that may assist with
smoking cessation, and community support systems
that may assist with psychological stressors

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