NR341 exam 1 test review|Qustions and answers

NR341 exam 1 test review|Qustions and answers 6:ekg 4:abg A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence A patient receives a 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which assessment should the nurse complete first? a. Verify the serum potassium level. b. Test for the presence of Chvostek’s sign. c. Observe for blood on the neck dressing. d. Confirm a prescription for thyroid replacement. The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning. Which action should the nurse take first when a patient develops epistaxis? a. Pack the affected area tight with an epistaxis balloon. b. Apply to squeeze pressure to the nostrils for 10 minutes. c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected area. A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Report of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid nonsteroidal anti-inflammatory drugs (NSAIDs). A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly sedentary. Which intervention will the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action should the nurse take? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient’s room. d. Schedule a 4-hour rest period for the patient. A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high Fowler’s position A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate the head of the bed to 30 to 45 degrees. b. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure. A patient admitted with acute respiratory failure has ineffective airway clearance from thick secretions. Which nursing intervention would specifically address this patient problem? a. Encourage the use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation above 93%. The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease (COPD). Which action should the nurse take first? a. Observe for facial symmetry. b. Notify the health care provider. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry. The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms. Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. “The pain wakes me up at night.” b. “The pain is level 3 to 5 (0 to 10 scale).” c. “The pain has worsened over the last week.” d. “The pain goes away after a nitroglycerin tablet.” Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has been effective? a. “I can expect nausea as a side effect of nitroglycerin.” b. “I should only take nitroglycerin when I have chest pain.” c. “Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.” d. “I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart.” A patient who has had chest pain for several hours is admitted with a diagnosis of rule-out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin Heparin is ordered for a non–ST-segment-elevation myocardial infarction (NSTEMI) patient. How should the nurse explain the purpose of the heparin to the patient? a. “Heparin enhances platelet aggregation at the plaque site.” b. “Heparin decreases the size of the coronary artery plaque.” c. “Heparin prevents the development of new clots in the coronary arteries.” d. “Heparin dissolves clots that are blocking blood flow in the coronary arteries.” Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with myocardial infarction (MI)? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias. Diltiazem (Cardizem) is prescribed for a patient with newly diagnosed Prinzmetal’s (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? a. Reduces heart palpitations. b. Prevents coronary artery plaque. c. Decreases coronary artery spasms. d. Increases the contractile force of the heart. A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as a focused follow-up on this symptom? a. Assess both feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? a. “Most patients can enjoy intercourse without any complications.” b. “Sexual activity uses about as much energy as climbing two flights of stairs.” c. “The doctor will provide sexual guidelines when your heart is strong enough.” d. “Holding and cuddling are good ways to maintain intimacy after a heart attack.” A patient who has recently started taking pravastatin (Pravachol) and niacin reported several symptoms to the nurse. Which information is most important to communicate to the healthcare provider? a. Generalized muscle aches and pains b. Dizziness with rapid position changes c. Nausea when taking the drugs before meals d. Flushing and pruritus after taking the drugs A