PN Medical-Surgical Nursing Final Exam deWit 3rd edition (100% Accurate Answers)

The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding should the nurse report immediately to the physician? A. Moderate shortness of breath after walking down the hall. B. A 3 pound weight gain over the course of a week. C. Heart rate of 104 beats/min after ambulating to the bathroom. D. Increase urinary output to 50 mL in the last hour. correct answers Answer: A. Shortness of breath after walking down the hall. The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take? A. Only use alcohol-based hand cleanser for hand hygiene. B. Always wear an impervious mask. C. Don proper eye protection before providing care. D. Put the patient on contact plus isolation. correct answers Answer: D. Put the patient on contact plus isolation The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential complication that warrants immediate attention? A. Increased lethargy B. Sudden coughing C. Elevated blood pressure D. Cloudy urine correct answers Answer: A. Increased lethargy The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates the nurse's teaching has been successful? A. "I will need to stay in bed when the monitor is reading my heart waves." B. "This test will help determine if I have a blockage in my arteries." C. "If there is a problem with my heart valves, it will show up with telemetry." D. "The nurses will be able to monitor my heart rate and rhythm." correct answers Answer: D. The nurses will be able to monitor my heart rate and rhythm. The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurses first action?