NR 341 Complex Adult Health Exam 2 Questions and Answers.

Exam 2 NR 341 1. The nurse is caring for a client with hypovolemic shock. The family member asks why the fluids are being warmed. What is the Best response by the nurse? “to prevent complications from hypothermia” 2. The nurse is caring for a newly admitted client diagnosed with acute kidney injury. The nurse understands that the acute kidney injury is Most likely related to a history of which condition? Sepsis 3. The nurse is caring for a client being monitored by arterial pressure monitoring. The nurse notes a systolic pressure of 164 mmHg. What action should the nurse take first ? Assess the client. 4. The nurse is caring for a client with an arteriovenous (AV) fistula. Upon assessment, the nurse is unable to auscultate a bruit. What action should the nurse take first? Notify the provider 5. The nurse is assessing jugular venous pressure. In what order should the nurse proceed with the steps in the process? [place the steps in the correct order beginning with the first step head of bed between 30-45 degrees. 2. Have client turn head slightly to the left. 6. Shine a pen light across the neck, assess for jugular venous distension at end of exhalation. ve the highest point of pulsation in the internal jugular vein at end exhalation. 4. Measure the vertical distance between the pulsation and the angle of louis. 1. Add 5 cm to the measurement. 6. The nurse is caring for a client with acute kidney injury. The nurse should anticipate which abnormal assessment finding? BUN/creatinine ratio 25:1 7. The nurse is caring for a client whose vital signs are monitored using invasive hemodynamic monitoring. Which action is most important for the nurse to implement to decrease the risk of infection? Strict hand washing 8. The nurse is preparing a client for placement of a catheter for arterial pressure monitoring. What is the best way for the nurse to assess ulnar circulation prior to catheter insertion? Occlude the radial artery. 9. The nurse is monitoring a client on hemodialysis. The nurse understands that which lab value has the highest potential to be abnormal and cause complications as a result of fluid imbalance? Electrolytes 10. The nurse is evaluating a client who is being treated for shock. When evaluating a client being treated for shock, what finding indicated an improvement in the client’s condition? Bun of 12 mg/DL FOR THE EXAM answer was: Creatinine 2.6mg/dL that’s too high: normal level is: 0.6 to 1.6mg/dL 11. The nurse is assessing a client during hemodialysis. Which finding should the nurse report to the health care provider immediately ? Redness at insertion site 12. When developing the plan of care for an older adult client with acute kidney injury, the nurse understands that it is essential to consider which factor in the client’s history? Recent use of antibiotics 13. The nurse is rounding on clients at the beginning of the shift.Which observation requires immediate action when caring for a client with a percutaneous catheter for dialysis? Gauze dressing over insertion site 14. The nurse is evaluating a client who is being treated for shock. Which findings indicates an improvement in the client’s condition? [select all that apply] Blood pressure 120/70 Bun of 12 mg/dL 15. Which statement by the client is most important for the nurse to communicate to the physical therapist when planning discharge care for a client who is recovering from an acute myocardial infarction? “I used to be active when I was younger, but now I just get so weak.” 16. The nurse is assessing the health history of a 61-year old client admitted with a diagnosis of acute myocardial infarction (AMI) secondary to coronary artery disease (CAD). Which factors contributes to the client’s condition? [select all that apply] Eats a fast food lunch 5 days a week. Blood pressure averages 150/90 mmHg. Family history of coronary artery disease .THIS QUESTION THE OPTIONS WERE CHANGED: LDL 160, EATS A FAST FOOD 5 DAYS A WEEKS, QUIT SMOKING 30 YRS AGO.. Don’t chose the red on.. 17. A clinic nurse is assessing a client with a history of a myocardial infarction for an annual health visit. What assessment data would the nurse follow up on in regards to the possibility of heart failure? Client states they get short of breath walking to their mailbox 18. A nurse is reviewing information with a client about the risk factors associated with heart failure. What information does the nurse provide to the client? A heart attack can increase the risk of developing heart failure. ,,,,,,look for this cause they change the wording 19. When caring for a client with pleural chest tube following a coronary artery bypass graft, what assessment finding would require further assessment? Increased output 20. A client comes to the emergency department (ED) with diaphoresis, nausea, and shoulder pain. What assessment data should the nurse obtain first ? 12-lead ECG