NUR 4045 Adult Health 2 EXAM II.

NUR 4045 Adult Health 2 EXAM II. 1. Patient on PEEP (believe) experiencing ARDS (select all that apply) a. Beta blocker b. Loop diuretic c. Bronchodilator d. Something else corticosterian Look it up 1. The nurse assists the provider with a liver biopsy at the bedside. Which position does the nurse put the patient in after the biopsy? Supine with head elevated on one pillow Semi-fowlers with two pillows under the leg Right side lying with a folded towel under the puncture site Left side lying with a small pillow under the puncture site 2. A patient is hospitalized for severe anorexia, fatigue, mild jaundice, hepatomegaly, and abnormal liver function tests. The physician suspects viral hepatitis. In planning care, which patient outcome does the nurse assign the highest priority? Maintains adequate nutrition Maintains usual exercise regimen Adapts to changes in appearance Definitely identifies source of exposure to hepatitis virus 3. Select all the potential causes for hepatic inflammation (double check this answer) Virus Penicillin Acetaminophen Alcohol Chocolate 4. A patient admitted to the hospital with a diagnosis of cirrhosis has a massive ascites’s and difficulty breathing. The nurse performers which intervention as a priority measure to assist the patient with breathing? Reposition side to side every 2 hours Auscultate the lung sounds every 4hours Encourage deep breathing exercises Elevate the head of the bed 60 degrees 5. A home health nurse visits a patient who was recently diagnosed with cirrhosis and provides home care management instructions to the patient. Which statement by the patient indicates the need for further instructions? I will obtain adequate rest I should monitor my weight regularly I should include sufficient carbs in my diet I will take acetaminophen (Tylenol) if I get a headache 6. The nurse administers lactulose to a patient with cirrhosis the patient complains of diarrhea. The nurse explains that it is important to take the drug for which effect? Prevention of constipation Promotion of fluid loss Reduction in serum ammonia levels Prevention of gastrointestinal bleeding 7. A patient with liver cancer has severe ascites and shortness of breath. The physician plans a paracentesis. The nurse prepares the patient for the paracentesis with which action? Have client empty bladder Position patient flat on right side Have them lie flat with a small pillow under the small of his back Sedate the client with versed 8. The patient is admitted to the ED with vomiting of bright red blood. Which info is most important for the nurse to obtain during assessment? Vital signs and symptoms of hypovolemia History of prior bleeding Medication client is taking Current medical problems 21. (WORDED DIFFERENTLY ON TEST): A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid 22. (WORDED DIFFERENTLY ON TEST): A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation 23. While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? The system is functioning normally. The patient has a pneumothorax. The system has an air leak. The chest tube is obstructed. 25. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds 27. The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? 70 Years old man who aspirated before A resident with mid-stage Alzheimers disease A 92-year-old resident who needs extensive help with ADLs A resident with severe and deforming rheumatoid arthritis 30. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? A) Attach the condom prior to erection. B) A condom may be reused with the same partner if ejaculation has not occurred. C) Use skin lotion as a lubricant if alternatives are unavailable. D) Hold the condom by the cuff upon withdrawal. 31.A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? A) 75 cells/mm3 of blood B) 200 cells/mm3 of blood C) 325 cells/mm3 of blood D) 450 cells/mm3 of blood 32. A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? A) Acute Abdominal Pain B) Diarrhea C) Bowel Incontinence D) Constipation 33. The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk? A) Providing thorough oral care before and after meals B) Administering prophylactic antibiotics C) Promoting nutrition and adequate fluid intake D) Applying skin emollients as needed 34. A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response? A) Theres no way to be sure you wont get HIV except to use condoms correctly. B) Only the correct use of a female condom protects against the transmission of HIV. C) There are new ways of protecting yourself from HIV that are being discovered every day. D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV. 35. A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? A) Promoting appropriate use of complementary therapies B) Addressing possible barriers to adherence C) Educating the patient about the pathophysiology of HIV D) Teaching the patient about the need for follow-up blood work 36. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action? A) Assess the patient for additional signs and symptoms of Kaposis sarcoma. B) Review the patients most recent viral load and CD4+ count. C) Place the patient on respiratory isolation and inform the physician. D) Perform oral suctioning to reduce the patients risk for aspiration. 37. A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores? A) Advera B) Momordicacharantia C) Megestrol (Exam said MEGACE) D) Ranitidine 39. A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A) Perianal region and oral mucosa B) Sacral region and lower abdomen C) Scalp and skin over the scapulae D) Axillae and upper thorax 40. A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needle stick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next? A) Flush the wound site with chlorhexidine. B) Report to the emergency department or employee health department. C) Apply a hydrocolloid dressing to the wound site. D) Follow up with the nurses primary care provider. 42. A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Butterfly rash C) Jaundice D) Skin sloughing 43. A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints 45. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? A) Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels. B) Ill try to be as physically active as possible between flare-ups. C) Avoid prolonged exposure to the sun D) Ill stop taking my steroids when I get relief from my symptoms. A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patients adherence to her medication regimen? A) Encourage the patient to store the bottles with their tops removed. B) Have a trusted family member take over the management of the patients medication regimen. C) Encourage her to have her pharmacy replace the tops with alternatives that are easier to open. D) Have the patient approach her primary care provider to explore medication alternatives. 49. A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? A) Maximize range of motion while minimizing exertion B) Increase joint size and strength C) Limit energy output in order to preserve strength for healing D) Preserve and increase range of motion while limiting joint stress 50. 2 given ABGs and STAT what it is ? 51. pulmonary edema = pink frothy sputum 52. After a nurse inspected the abdomen, what should she do next? Auscultate all 4 quadrants 53. A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. Immunization Use of standard precautions 55. A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? Blood glucose levels 56. A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? IV hydromorphone (Dilaudid) 57. The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient’s respirations. How should the nurse best respond to this assessment finding? Document that the chest drainage system is operating as it is intended. 1. You are a nurse and you put in an NG tube, what is your next step? - Verify placement by x-ray 2. What is an early symptom of pulmonary edema? - Agitation and restlessness 3. Who is at greatest risk for Acute Respiratory Distress? - Patient who has aspirated (aspiration because fluid can go into wrong pipe) 4. An endotracheal tube just went into a patient, how do you verify it is in the right place? - Capnography: measures CO2 5. If a patient is on mechanical ventilation, why do you think we need to give them humidity? - O2 dry’s them out – so you want to prevent that 6. Patient has bruising in arms and legs. What type of tests would you do? - CBC and coagulation studies 7. What diet would a patient with ascites be on? - Low sodium diet 8. How do you diagnosis esophageal varices? - Endoscopy The nurse is preparing to perform a patient’s abdominal assessment. What examination sequence should the nurse follow? A) Inspection, auscultation, percussion, and palpation