Adult Health III: Final Exam Questions And Answers

Adult Health III: Final Exam Questions And Answers /.The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. skin cool and clammy b. heart rate of 118 beats/min c. blood pressure of 92/56 d. O2 saturation of 93% on room air - Answer-Answer: a /.Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. the patient's respiratory rate is 32 breaths/min b. the patient has occasional audible expiratory wheezes c. the patient's oxygen saturation drops to 93% d. the patient was last suctioned 6 hours ago - Answer-Answer: a /.The nurse in the emergency department is caring for a client with a history of smoking who is obese and admitted with epigastric pain. The client is diagnosed with abdominal aortic aneurysm after having an X-ray. During assessment the nurse notes ecchymosis to the client's back side. Which of the following actions would be priority for the nurse to take? a. prepare the client for a blood transfusion b. obtain informed consent for emergency surgery c. obtain the client's blood pressure d. assess the client's lung sounds - Answer-Answer: b /.The nurse is caring for a client who is experiencing neurogenic shock after a spinal cord injury. The nurse has taught the client's spouse about neurogenic shock. Which of the following statements by the client's spouse requires follow-up? a. this type of shock causes excessive urine loss b. my spouse may have difficulty maintaining normal body temperature c. this type of shock causes the heart rate to be too low d. my spouse is receiving medicine to keep the blood pressure high enough - Answer-Answer: a /.The nurse is caring for a client who was exposed to inhalation anthrax and is to receive prescribed ciprofloxacin 800mg, once per day, IV for 60 days. The nurse has 800mg/250mL in D5W to be infused over 2 hours. How many mL per hour should the nurse administer? Do not round your answer. Enter numeric value only. - Answer-Answer: 125 /.A nurse is caring for a client experiencing atrial flutter in the telemetry monitor. Which of the following characteristics and manifestations should the nurse expect to see? Select all that apply. a. shortened PR interval b. Hypertension c. an irregular atrial rate that is between 350 and 600 beats/min d. Normal QRS complex e. Alcohol intoxication f. a regular ventricular rate that is greater than or less than 100 beats/min - Answer-Answer: a, c, f /.The nurse is assessing a client with a head injury who is exhibiting an altered level of consciousness (LOC) and had clear fluid leaking from the right ear. Which of the following actions would be priority for the nurse to take? a. prepare the client for surgery b. monitor the client for increased intercranial pressure (ICP) c. insert a peripheral intravenous catheter d. provide seizure precautions - Answer-Answer: b /.Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. a patient who has twice-daily burn debridements to partial-thickness facial burns b. a patient who just returned from having a cultured epithelial autograft to the chest c. a patient who has blebs under an autograft on the thigh and has an order for bleb aspiration d. a patient who has a 15% body weight loss from admission and will need enteral feedings - Answer-Answer: d /.A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. give the prescribed hydromorphone (Dilaudid) b. auscultate for breath sounds c. determine the extent and depth of the burns resuscitative infuse the prescribed lactated ringer's solution - Answer-Answer: b /.The nurse is planning an education conference about calculating the client's heart rate forma telemetry strip. Which of the following information should the nurse include in the conference? Select all that apply. a. count the number of QRS complexes seen in one minute b. count the number of large squares between an R to R interval and divide the number into 300 c. count the number of small squares between the R to R interval and divide the number into 1500 d. count the number of P to P intervals in 6 seconds and multiply that number by 10 e. count the number of P waves you see in a 6 second strip and divide the number into 300 - Answer-Answer: a, b, c /.The nurse is caring for a child with a severe allergic reaction who has a prescription for diphenhydramine 1.25mg/kg, IV times one. The nurse has 50mg/mL available. The client weighs 45kg. How many mL should the nurse administer to the client? Round your answer to the nearest tenth place. Enter numeric value only. - Answer-Answer: 1.1 /.The nurse has repositioned a client that has a ventriculostomy system for monitoring increased intercranial pressure (ICP). Which of the following actions should be a priority for the nurse to take? a. monitor the waveform b. ensure the system is level with the client's foramen of Monro c. administer pain medication to the client d. obtain a sample of cerebral spinal fluid (CSF) from the system - Answer-Answer: b /.An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do? a. give PRN lorazepam (Ativan) and cancel the transfer b. inform the receiving nurse and then transfer the patient c. notify the healthcare provider and postpone the transfer d. obtain an order for restraints as needed and transfer the patient - Answer-Answer: b (c?) /.The nurse is planning a staff education conference about shock. Which of the following information would be appropriate for the nurse to include in the conference? a. IV fluid administration is important for all types of shock b. the client is not experiencing shock if the skin is warm c. shock is the same thing as sepsis d. shock may manifest as anxiety - Answer-Answer: d /.The nurse is teaching the spouse of a client who has expressive aphasia following a stroke about facilitating communication. Which of the following information should the nurse include in the teaching? a. ask questions like, "Do you want his or that for dinner?" while giving some options, instead of "What do you want for dinner?" b. you should give your spouse as many options as possible and then say, "Just point to what you want" c. if your spouse becomes frustrated, it is best to say "okay" and then walk away for a short while d. let your spouse write down everything to avoid exhaustion and confusion - Answer-Answer: a /.The nurse is admitting a client with a diagnosis of gastrointestinal (GI) bleed who is in the compensatory stage of shock. Which of the following assessment findings should the nurse expect to find?