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Clinical Procedures - CH. 4 Vital Sig... Chapter 35: Medication Administrati... Mod 10-12 - Key Points (Exam 3) Ex
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Terms in this set (75)
1. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full
The nurse is taking the health history of a exhalation. A patient with COPD would have a decrease in FVC. Incorrect.
patient being treated for Emphysema and
Chronic Bronchitis. After being told the 2. A narrowed chest cavity
patient has been smoking cigarettes for A patient with COPD often presents with a 'barrel chest,' which is seen as a
30 years, the nurse expects to note which widened chest cavity. Incorrect.
assessment finding?
3. Clubbed fingers - CORRECT
1. Increase in Forced Vital Capacity (FVC) Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
2. A narrowed chest cavity
3. Clubbed fingers 4. An increased risk of cardiac failure
4. An increased risk of cardiac failure Although a patient with these conditions would indeed be at an increased risk for
cardiac failure, this is a potential complication and not an assessment finding.
Incorrect.
1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as
black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the
The nurse is taking the health history of a Duodenum is further down the gastric anatomy.
70-year-old patient being treated for a
Duodenal Ulcer. After being told the 2. Nausea
patient is complaining of epigastric pain, Nausea may be present, but is a generalized symptom and by itself doesn't
the nurse expects to note which indicate a Duodenal Ulcer. Incorrect.
assessment finding?
3. Hernia
1. Melena A Hernia is a protrusion of a segment of the abdomen through another abdominal
2. Nausea structure. It is not associated with an Ulcer and is a condition, not an assessment
3. Hernia finding. Incorrect.
4. Hyperthermia
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal
Ulcer. Incorrect
,A nurse is providing discharge teaching 1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
for a patient with severe CORRECT - Large meals increase the volume and pressure in the stomach and
Gastroesophogeal Reflux Disease. Which delay gastric emptying. It's recommended instead to eat 4-6 small meals a day.
of these statements by the patient
indicates a need for more teaching? 2. "I'm going to make sure to remain upright after meals and elevate my head
when I sleep"
1. "I'm going to limit my meals to 2-3 per Incorrect - This is a correct verbalization of health promotion for GERD.
day to reduce acid secretion."
3. "I won't be drinking tea or coffee or eating chocolate any more."
2. "I'm going to make sure to remain Incorrect - This is a correct verbalization of health promotion for GERD.
upright after meals and elevate my head
when I sleep" 4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or
eating chocolate any more."
4. "I'm going to start trying to lose some
weight."
1. Start a large-bore IV in the patient's arm
The nurse in the Emergency Room is CORRECT - The nurse should suspect that the patient is haemorrhaging and will
treating a patient suspected to have a need need a fluid replacement therapy, which requires a large bore IV.
Peptic Ulcer. On assessing lab results, the
nurse finds that the patient's blood 2. Ask the patient for a stool sample
pressure is 95/60, pulse is 110 beats per Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer
minute, and the patient reports epigastric Disease, it is not the priority intervention.
pain. What is the PRIORITY intervention?
3. Prepare to insert an NG Tube
1. Start a large-bore IV in the patient's arm Incorrect - While this intervention may be used in the later stages of Peptic Ulcer
2. Ask the patient for a stool sample Disease, it is not the first and priority intervention.
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine 4. Administer intramuscular morphine sulphate as ordered
sulphate as ordered Incorrect - While this is an important intervention to manage pain, it is not the
priority intervention.
1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more
A female patient with atrial fibrillation has
critical lab result.
the following lab results: Hemoglobin of
11 g/dl, a platelet count of 150,000, an INR
2. Platelet of 150,000
of 2.5, and potassium of 2.7 mEq/L. Which
This is also below the normal values, but is not the most critical lab result.
result is critical and should be reported to
the physician immediately?
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial
1. Hemoglobin 11 g/dl
fibrillation
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L
4. Potassium of 2.7 mEq/L
CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can
be life-threatening and can lead to cardiac distress.
, 1. Stop the saline infusion immediately
While receiving normal saline infusions to
CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid
treat a GI bleed, the nurse notes that the
replacement. The nurse should stop the infusion and notify the physician.
patient's lower legs have become
edematous and auscultates crackles in the
2. Notify Physician
lungs. What should the nurse do first?
This is not the first action the nurse should take.
1. Stop the saline infusion immediately
3. Elevate the patient's legs
2. Notify Physician
This would help with the edema, but is not a priority
3. Elevate the patient's legs
4. Continue the infusion, since these are
4. Continue the infusion, since these are normal findings
normal findings
This is not a normal finding
1. They must inform household members of their condition
Incorrect - Each patient has a right to privacy of their medical condition. It is their
choice whether they inform household members.
The nurse is working in a support group
for clients with HIV. Which point is most 2. They must take their medications exactly as prescribed
important for the nurse to stress? CORRECT - Antiretrovirals must be taken exactly as prescribed to prevent drug-
resistant strains. Even missed doses can reduce the effectiveness of future
1. They must inform household members treatment.
of their condition
2. They must take their medications 3. They must abstain from substance use
exactly as prescribed Incorrect - While substance use should be discouraged, using safe practices with
3. They must abstain from substance use needles can prevent transmission of HIV.
4. They must avoid large crowds
4. They must avoid large crowds
Incorrect - Avoiding large crowds to prevent infection is a priority in the later
stages of HIV, when the patient has AIDS.
1. Initiate cardiopulmonary resuscitation
Incorrect - CPR is premature at this point, and there is another action that can be
A nurse finds a 30-year-old woman
taken first.
experiencing anaphylaxis from a bee
sting. Emergency personnel have been
2. Check for a pulse
called. The nurse notes the woman is
This is the first step when assessing for initiation of CPR, but CPR is not the best
breathing but short of breath. Which of
and first course of action for this situation. The woman is still breathing, which
the following interventions should the
means CPR is not necessary at this time.
nurse do first?
3. Ask the woman if she carries an emergency medical kit
1. Initiate cardiopulmonary resuscitation
CORRECT - Many patients who have a known history of anaphylaxis carry epi-
2. Check for a pulse
pens in their pockets or belongings. This is the best way to stop a hypersensitivity
3. Ask the woman if she carries an
reaction before it becomes life-threatening.
emergency medical kit
4. Stay with the woman until help comes
3. Stay with the woman until help comes
Incorrect - While this should be done, it's not the best and first course of action.
75 Free NCLEX Questions - c/o BrilliantNurse.com
155 studiers today 4.6 (141 reviews)
Save
Students also studied
Clinical Procedures - CH. 4 Vital Sig... Chapter 35: Medication Administrati... Mod 10-12 - Key Points (Exam 3) Ex
88 terms 24 terms 46 terms 16
addisonirlbeck06 Preview Ashley_Ca7 Preview autumngraham065 Preview
Terms in this set (75)
1. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full
The nurse is taking the health history of a exhalation. A patient with COPD would have a decrease in FVC. Incorrect.
patient being treated for Emphysema and
Chronic Bronchitis. After being told the 2. A narrowed chest cavity
patient has been smoking cigarettes for A patient with COPD often presents with a 'barrel chest,' which is seen as a
30 years, the nurse expects to note which widened chest cavity. Incorrect.
assessment finding?
3. Clubbed fingers - CORRECT
1. Increase in Forced Vital Capacity (FVC) Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
2. A narrowed chest cavity
3. Clubbed fingers 4. An increased risk of cardiac failure
4. An increased risk of cardiac failure Although a patient with these conditions would indeed be at an increased risk for
cardiac failure, this is a potential complication and not an assessment finding.
Incorrect.
1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as
black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the
The nurse is taking the health history of a Duodenum is further down the gastric anatomy.
70-year-old patient being treated for a
Duodenal Ulcer. After being told the 2. Nausea
patient is complaining of epigastric pain, Nausea may be present, but is a generalized symptom and by itself doesn't
the nurse expects to note which indicate a Duodenal Ulcer. Incorrect.
assessment finding?
3. Hernia
1. Melena A Hernia is a protrusion of a segment of the abdomen through another abdominal
2. Nausea structure. It is not associated with an Ulcer and is a condition, not an assessment
3. Hernia finding. Incorrect.
4. Hyperthermia
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal
Ulcer. Incorrect
,A nurse is providing discharge teaching 1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
for a patient with severe CORRECT - Large meals increase the volume and pressure in the stomach and
Gastroesophogeal Reflux Disease. Which delay gastric emptying. It's recommended instead to eat 4-6 small meals a day.
of these statements by the patient
indicates a need for more teaching? 2. "I'm going to make sure to remain upright after meals and elevate my head
when I sleep"
1. "I'm going to limit my meals to 2-3 per Incorrect - This is a correct verbalization of health promotion for GERD.
day to reduce acid secretion."
3. "I won't be drinking tea or coffee or eating chocolate any more."
2. "I'm going to make sure to remain Incorrect - This is a correct verbalization of health promotion for GERD.
upright after meals and elevate my head
when I sleep" 4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or
eating chocolate any more."
4. "I'm going to start trying to lose some
weight."
1. Start a large-bore IV in the patient's arm
The nurse in the Emergency Room is CORRECT - The nurse should suspect that the patient is haemorrhaging and will
treating a patient suspected to have a need need a fluid replacement therapy, which requires a large bore IV.
Peptic Ulcer. On assessing lab results, the
nurse finds that the patient's blood 2. Ask the patient for a stool sample
pressure is 95/60, pulse is 110 beats per Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer
minute, and the patient reports epigastric Disease, it is not the priority intervention.
pain. What is the PRIORITY intervention?
3. Prepare to insert an NG Tube
1. Start a large-bore IV in the patient's arm Incorrect - While this intervention may be used in the later stages of Peptic Ulcer
2. Ask the patient for a stool sample Disease, it is not the first and priority intervention.
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine 4. Administer intramuscular morphine sulphate as ordered
sulphate as ordered Incorrect - While this is an important intervention to manage pain, it is not the
priority intervention.
1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more
A female patient with atrial fibrillation has
critical lab result.
the following lab results: Hemoglobin of
11 g/dl, a platelet count of 150,000, an INR
2. Platelet of 150,000
of 2.5, and potassium of 2.7 mEq/L. Which
This is also below the normal values, but is not the most critical lab result.
result is critical and should be reported to
the physician immediately?
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial
1. Hemoglobin 11 g/dl
fibrillation
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L
4. Potassium of 2.7 mEq/L
CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can
be life-threatening and can lead to cardiac distress.
, 1. Stop the saline infusion immediately
While receiving normal saline infusions to
CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid
treat a GI bleed, the nurse notes that the
replacement. The nurse should stop the infusion and notify the physician.
patient's lower legs have become
edematous and auscultates crackles in the
2. Notify Physician
lungs. What should the nurse do first?
This is not the first action the nurse should take.
1. Stop the saline infusion immediately
3. Elevate the patient's legs
2. Notify Physician
This would help with the edema, but is not a priority
3. Elevate the patient's legs
4. Continue the infusion, since these are
4. Continue the infusion, since these are normal findings
normal findings
This is not a normal finding
1. They must inform household members of their condition
Incorrect - Each patient has a right to privacy of their medical condition. It is their
choice whether they inform household members.
The nurse is working in a support group
for clients with HIV. Which point is most 2. They must take their medications exactly as prescribed
important for the nurse to stress? CORRECT - Antiretrovirals must be taken exactly as prescribed to prevent drug-
resistant strains. Even missed doses can reduce the effectiveness of future
1. They must inform household members treatment.
of their condition
2. They must take their medications 3. They must abstain from substance use
exactly as prescribed Incorrect - While substance use should be discouraged, using safe practices with
3. They must abstain from substance use needles can prevent transmission of HIV.
4. They must avoid large crowds
4. They must avoid large crowds
Incorrect - Avoiding large crowds to prevent infection is a priority in the later
stages of HIV, when the patient has AIDS.
1. Initiate cardiopulmonary resuscitation
Incorrect - CPR is premature at this point, and there is another action that can be
A nurse finds a 30-year-old woman
taken first.
experiencing anaphylaxis from a bee
sting. Emergency personnel have been
2. Check for a pulse
called. The nurse notes the woman is
This is the first step when assessing for initiation of CPR, but CPR is not the best
breathing but short of breath. Which of
and first course of action for this situation. The woman is still breathing, which
the following interventions should the
means CPR is not necessary at this time.
nurse do first?
3. Ask the woman if she carries an emergency medical kit
1. Initiate cardiopulmonary resuscitation
CORRECT - Many patients who have a known history of anaphylaxis carry epi-
2. Check for a pulse
pens in their pockets or belongings. This is the best way to stop a hypersensitivity
3. Ask the woman if she carries an
reaction before it becomes life-threatening.
emergency medical kit
4. Stay with the woman until help comes
3. Stay with the woman until help comes
Incorrect - While this should be done, it's not the best and first course of action.
