Med Surg 3 Final Exam questions and answers well illustrated.

Med Surg 3 Final Exam questions and answers well illustrated. The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? - correct answers.Reduced number of pacemaker cells in the SA node Rationale: A reduced number of pacemaker cells in the SA node causes the maximum heart rate to decrease with age, leading to bradycardia. The nurse is providing care to an older adult patient who is diagnosed with congestive heart failure (CHF). When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? - correct answers.Increased size of the left atrium Rationale: Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible for an increased risk for hypertension and congestive heart failure (CHF). The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? - correct answers.Decreased cardiac responsiveness to beta-adrenergic stimuli Rationale: Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors. Which electrolyte imbalance should the nurse monitor an older adult patient for due to impaired renal diluting capacity and concentrating ability? - correct answers.Hyponatremia Rationale: Sodium imbalances occur due to impaired renal diluting capacity and concentrating ability. Which clinical manifestation does the nurse anticipate when providing care to an older adult patient diagnosed with failure to thrive (FTT)? - correct answers.Skin that loses elasticity with poor turgor Rationale: Dehydration, manifested with decreased elasticity and turgor of the skin, supports the diagnosis of FTT. The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis? - correct answers.Dyspnea Rationale: Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS. The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am having trouble breathing." Based on this data, which does the nurse suspect the patient is experiencing? - correct answers.Acute respiratory distress syndrome Rationale: Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The patient has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the patient is developing acute respiratory A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this patient? - correct answers.Impaired Spontaneous Ventilation Rationale: A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the patient could experience respiratory arrest. A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient? - correct answers.Place in the Fowler position Rationale: Weaning a patient from mechanical ventilation should begin in the morning when the patient is well-rested. The patient should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient? - correct answers.Airway maintenance with cervical spine protection When caring for the trauma victim the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern is airway maintenance with cervical spine protection. The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS? - correct answers.Tachypnea Ratioanle: Dyspnea and tachypnea are early clinical manifestations of ARDS. The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation? - correct answers.Urine output 25mL/hr Rationale:Decreased cardiac output is supported by a decrease of urine output. Expected urine output is at least 30 mL/hr. This patient's urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output. A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient? - correct answers.Mechanical ventilation Rationale: With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen-the percentage of oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than 60 mm Hg and oxygen saturation of approximately 90%. It is important to remember that mechanical ventilation does not cure ARDS; it simply supports respiratory function while the underlying problem is identified and treated. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse's suspicion? - correct answers.Dyspnea and shortness of breath Rationale: Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever. The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse's concern? - correct answers.Body mass index (BMI) 35.8 Rationale: Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the patient's risk of developing a thrombus and possible pulmonary embolism. The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient's risk for developing a thrombosis or pulmonary embolism? - correct answers.Use compression stockings Rationale: A patient being discharged after having orthopedic surgery is at increased risk for pulmonary embolism. The nurse should instruct the patient to continue with leg exercises and use compression stockings to reduce the risk of deep vein thrombosis formation.