NSG 430 FINAL EXAM - COMPLETE QUESTIONS
AND DETAILED SOLUTIONS LATEST UPDATE JUST
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Question 1: A pt has been admitted with severe leg pain. The limb
is cyanotic, cool to the touch, peripheral pulses absent. What is the
priority nursing action
A. Document the findings
B. Teach relaxation techniques
C. Notify physician immediately
D. Ask how long the limb has been hurting
Answer:
c. Notify physician immediately
Question 2: A patient is prescribed lovastatin for hyperlipidemia.
What should the nurse instruct the pt about this medication (select
all that apply)
A. Avoid etoh
B. Take with meals o minimize gi distress
C. Promptly report muscle pain or tenderness to physician
D. Consume diet that includes no more than 20% of calories from
saturated fat
E. Expect periodic LFTs to be drawn while taking med
Answer:
a. Avoid etoh
e. Expect periodic LFTs to be drawn while taking med
Question 3: The nurse is taking care of a pt recovering from
coronary angioplasty with stent placement. Which intervention is a
,priority for the pt at this time.
A. Securing chest tubes to bedding
B. Maintain leg extension on affected side
C. Dc iv lines hen tsking po fluids
D. Tx chest pain with IV morphine prn
Answer:
b. Maintain leg extension on affected side
Question 4: A pt is a potential candidate for fibrinolytic therapy.
The nurse understands that which findings may make that tx
contraindicated (select all that apply)
A. The pt is very anxious
B. The pt had gastric bypass two mos ago
C. The pt was in a mva last week
D. The pt bmi is obese
E. The pt takes meds to ctrl essential htn
Answer:
b. The pt had gastric bypass two mos ago
c. The pt was in a mva last week
Question 5: The nurse is reviewing labs for pt with acute chest
pain. Which lab value is most concerning
A. Ast 65
B. Ck 320
C. Hct 35
D. APTT 35
Answer:
b. Ck 320
,Question 6: The nurse recognizes that a pt has developed a second
degree av block type 2 (mobitz ii). What action should the nurse
take at this time
A. Record finding in chart
B. Place pt in fowlers position
C. Prepare for temporary pacemaker
D. Administer a class IB antidysrhythmic
Answer:
c. Prepare for temporary pacemaker
Question 7: A patient is dx with LV failure. Which findings are
consistent with this diagnosis (select all that apply)
A. Fatigue
B. Substernal chest pain during exercise
C. 5cm jugular vein distension at 30 degrees
D. Bilateral inspiratory crackles midscapulae
E. Complaints oof sob with minimal exertion
Answer:
a. Fatigue
d. Bilateral inspiratory crackles midscapulae
e. Complaints oof sob with minimal exertion
Question 8: The nurse is caring for a pt undergoing pulmonary
artery pressure monitoring. What should the nurse include when
caring for thee pt (select all that apply)
A. Maintain flush solution flow by gravity
B. Calibrate and level the system every shift
C. Secure iv line to bed linens
D. Change tubing to the insertion site every 72h
E. Measure pressure at the point of maximum inspiration
, Answer:
b. Calibrate and level the system every shift
d. Change tubing to the insertion site every 72h
Question 9: The nurse is planning care for a patient with acute
infective endocarditis. What would be an appropriate goal of
nursing care for this pt?
A. Resume usual activities within 1 week of tx
B. Relate the benign and self-limiting nature of the disease
C. Consider cardiac transplant as a viable tx option
D. State the importance of continuing iv abx as ordered
Answer:
d. State the importance of continuing iv abx as ordered
Question 10: The nurse is assessing heart sounds of a pt
scheduled for mitral valve replacement d/t mitral stenosis. Which
sounds should the nurse expect to auscultate (select all that apply)
A. Loud s1
B. Muffled heart sounds
C. S3 and s4
D. Diastolic murmur heard at apex
E. A low-pitched rumbling
Answer:
a. Loud s1
d. Diastolic murmur heard at apex
e. A low-pitched rumbling
Question 11: A pt is considering heart valve replacement and asks
if a biologic or mechanical valve is better to use. How should the
AND DETAILED SOLUTIONS LATEST UPDATE JUST
RELEASED
Question 1: A pt has been admitted with severe leg pain. The limb
is cyanotic, cool to the touch, peripheral pulses absent. What is the
priority nursing action
A. Document the findings
B. Teach relaxation techniques
C. Notify physician immediately
D. Ask how long the limb has been hurting
Answer:
c. Notify physician immediately
Question 2: A patient is prescribed lovastatin for hyperlipidemia.
What should the nurse instruct the pt about this medication (select
all that apply)
A. Avoid etoh
B. Take with meals o minimize gi distress
C. Promptly report muscle pain or tenderness to physician
D. Consume diet that includes no more than 20% of calories from
saturated fat
E. Expect periodic LFTs to be drawn while taking med
Answer:
a. Avoid etoh
e. Expect periodic LFTs to be drawn while taking med
Question 3: The nurse is taking care of a pt recovering from
coronary angioplasty with stent placement. Which intervention is a
,priority for the pt at this time.
A. Securing chest tubes to bedding
B. Maintain leg extension on affected side
C. Dc iv lines hen tsking po fluids
D. Tx chest pain with IV morphine prn
Answer:
b. Maintain leg extension on affected side
Question 4: A pt is a potential candidate for fibrinolytic therapy.
The nurse understands that which findings may make that tx
contraindicated (select all that apply)
A. The pt is very anxious
B. The pt had gastric bypass two mos ago
C. The pt was in a mva last week
D. The pt bmi is obese
E. The pt takes meds to ctrl essential htn
Answer:
b. The pt had gastric bypass two mos ago
c. The pt was in a mva last week
Question 5: The nurse is reviewing labs for pt with acute chest
pain. Which lab value is most concerning
A. Ast 65
B. Ck 320
C. Hct 35
D. APTT 35
Answer:
b. Ck 320
,Question 6: The nurse recognizes that a pt has developed a second
degree av block type 2 (mobitz ii). What action should the nurse
take at this time
A. Record finding in chart
B. Place pt in fowlers position
C. Prepare for temporary pacemaker
D. Administer a class IB antidysrhythmic
Answer:
c. Prepare for temporary pacemaker
Question 7: A patient is dx with LV failure. Which findings are
consistent with this diagnosis (select all that apply)
A. Fatigue
B. Substernal chest pain during exercise
C. 5cm jugular vein distension at 30 degrees
D. Bilateral inspiratory crackles midscapulae
E. Complaints oof sob with minimal exertion
Answer:
a. Fatigue
d. Bilateral inspiratory crackles midscapulae
e. Complaints oof sob with minimal exertion
Question 8: The nurse is caring for a pt undergoing pulmonary
artery pressure monitoring. What should the nurse include when
caring for thee pt (select all that apply)
A. Maintain flush solution flow by gravity
B. Calibrate and level the system every shift
C. Secure iv line to bed linens
D. Change tubing to the insertion site every 72h
E. Measure pressure at the point of maximum inspiration
, Answer:
b. Calibrate and level the system every shift
d. Change tubing to the insertion site every 72h
Question 9: The nurse is planning care for a patient with acute
infective endocarditis. What would be an appropriate goal of
nursing care for this pt?
A. Resume usual activities within 1 week of tx
B. Relate the benign and self-limiting nature of the disease
C. Consider cardiac transplant as a viable tx option
D. State the importance of continuing iv abx as ordered
Answer:
d. State the importance of continuing iv abx as ordered
Question 10: The nurse is assessing heart sounds of a pt
scheduled for mitral valve replacement d/t mitral stenosis. Which
sounds should the nurse expect to auscultate (select all that apply)
A. Loud s1
B. Muffled heart sounds
C. S3 and s4
D. Diastolic murmur heard at apex
E. A low-pitched rumbling
Answer:
a. Loud s1
d. Diastolic murmur heard at apex
e. A low-pitched rumbling
Question 11: A pt is considering heart valve replacement and asks
if a biologic or mechanical valve is better to use. How should the
