adult health 2 test 1
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1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses
the client to be disoriented to individual, area, and time. What motion by using the nurse is
exceptional?
A. Assess the clients pupillary responses.
B. Request a neurologic consultation.
C. Stop the infusion and call the provider.
D. Take and record a complete set of important symptoms. - ANS-ANS: C
A alternate in neurologic status in a customer receiving t-PA could indicate intracranial
hemorrhage. The nurse need to prevent the infusion and notify the provider at once. A complete
assessment, consisting of pupillary responses and critical symptoms, occurs subsequent. The
nurse might also or won't need to name a neurologist.
1. A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation.
Which manifestations should the nurse discover as unfavorable outcomes of this medication?
(Select all that practice.) a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Impaired judgment
e. Increased thirst - ANS-ANS: A, D
Varenicline (Chantix) has a black box caution declaring that the drug can reason manic conduct
and hallucinations. The nurse ought to check for changes in conduct and notion techniques,
consisting of impaired judgment and visible hallucinations. Tachycardia and increased thirst are
not detrimental outcomes of this remedy. Decreased cravings is a healing response to this
medicine.
DIF: Understanding
1. A nurse assesses a clients electrocardiograph tracing and observes that now not all QRS
complexes are preceded through a P wave. How need to the nurse interpret this statement?
A. The customer has hyperkalemia causing abnormal QRS complexes.
B. Ventricular tachycardia is overriding the normal atrial rhythm.
C. The clients chest leads aren't making sufficient contact with the pores and skin. D. Ventricular
and atrial depolarizations are initiated from distinctive sites.
. - ANS-ANS: D
,Normal rhythm suggests one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes with out a P wave suggest a
specific supply of initiation of depolarization. This finding on an electrocardiograph tracing is not
an illustration of hyperkalemia, ventricular tachycardia, or disconnection of leads
1. A nurse is being concerned for a customer with a records of renal insufficiency who's
scheduled for a cardiac catheterization. Which moves need to the nurse take previous to the
catheterization? (Select all that apply.) a. Assess for hypersensitive reactions to iodine.
B. Administer intravenous fluids.
C. Assess blood urea nitrogen (BUN) and creatinine outcomes.
D. Insert a Foley catheter.
E. Administer a prophylactic antibiotic.
F. Insert a valuable venous catheter. - ANS-ANS: A, B, C
If the customer has kidney ailment (as indicated by means of BUN and creatinine
consequences), fluids and Mucomyst may be given 12 to 24 hours earlier than the technique for
renal protection. The patron need to be assessed for allergies to iodine, which includes shellfish;
the evaluation medium used in the course of the catheterization contains iodine. A Foley
catheter and crucial venous catheter are not required for the manner and would most effective
boom the clients hazard for contamination. Prophylactic antibiotics are not administered
previous to a cardiac catheterization.
1. A nurse obtains the health history of a client who's lately identified with lung cancer and
identifies that the customer has a 60pack-yr smoking history. Which movement is maximum
crucial for the nurse to take when interviewing this purchaser?
A. Tell the patron that he wishes to give up smoking to forestall in addition cancer improvement.
B. Encourage the client to be absolutely sincere approximately each tobacco and marijuana
use. C. Maintain a nonjudgmental mindset to avoid causing the customer to sense guilty.
D. Avoid giving the consumer false hope regarding cancer treatment and analysis. - ANS-ANS:
C
Smoking history consists of the usage of cigarettes, cigars, pipe tobacco, marijuana, and
different managed substances. Because the customer might also have guilt or denial
approximately this habit, anticipate a nonjudgmental attitude at some point of the interview. This
will inspire the patron to be honest approximately the exposure. Ask the customer whether any
of those substances are used now or were used in the beyond. Assess whether the patron has
passive publicity to smoke within the home or workplace. If the customer smokes, ask for the
way long, what number of packs in step with day, and whether she or he has cease smoking
(and how long ago). Document the smoking history in p.C.-years (quantity of packs smoked
daily increased by way of the range of years the patron has smoked). Quitting smoking may not
prevent in addition cancer development. This declaration could be giving the patron false hope,
which need to be averted, however is not as critical as retaining a nonjudgmental attitude.
DIF: Applying
1. A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The
issuer prescribes zero.9% ordinary saline to infuse at a hundred twenty five mLhr for renal
,safety. The nurse obtains gravity tubing with a drip price of 15 dropsmL. At what charge
(dropsmin) must the nurse infuse the fluids? (Record your solution the usage of an entire
number, and rounding to the closest drop.) _____ drops - ANS-ANS:
31 drops
1.A 242-pound customer is being automatically ventilated. To save you lung damage, what
putting have to the nurse expect for tidal quantity? (Record your solution the use of an entire
wide variety.) ___ mL - ANS-ANS:
660 mL
A low tidal quantity of 6 mLkg is used to save you lung damage.
242 kilos = one hundred ten kg.
A hundred and ten kg x6 mLkg = 660 mL.
1.A nurse solutions a call light and reveals a consumer stressful, quick of breath, reporting chest
pain, and having a blood strain of 88/52 mm Hg on the cardiac reveal. What movement by
means of the nurse takes priority?
A. Assess the customers lung sounds.
B. Notify the Rapid Response Team.
C. Provide reassurance to the consumer.
D. Take a complete set of crucial signs and symptoms. - ANS-ANS: B
This consumer has manifestations of a pulmonary embolism, and the most vital action is to
inform the Rapid Response Team for quick analysis and remedy. The different movements are
appropriate also but are not the priority.
1.A nurse is worrying for five clients. For which customers might the nurse examine a high
danger for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to comparison dye the day gone by
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged guy with an exacerbation of bronchial asthma
d. Older customer who is 1-day submit hip alternative surgical procedure
e. Young overweight customer with a fractured femur - ANS-ANS: B, D, E
Conditions that location clients at higher risk of developing PE consist of prolonged immobility,
critical venous catheters, surgical procedure, obesity, advancing age, situations that growth
blood clotting, records of thromboembolism, smoking, pregnancy, estrogen remedy, coronary
heart failure, stroke, cancer (in particular lung or prostate), and trauma. A assessment dye
reaction and allergies pose no danger for PE.
10. A consumer in the cardiac stepdown unit reviews extreme, crushing chest pain observed
through nausea and vomiting. What action via the nurse takes priority?
A. Administer an aspirin.
B. Call for an electrocardiogram (ECG).
C. Maintain airway patency.
D. Notify the provider. - ANS-ANS: C
, Airway always is the concern. The different actions are vital in this situation as well, but the
nurse should live with the patron and ensure the airway stays patent (especially if vomiting
happens) at the same time as another individual calls the provider (or Rapid Response Team)
and enables getting an ECG performed. Aspirin will probably be administered, depending on the
vendors prescription and the clients modern-day medicines.
10. A nurse assesses a consumer who's scheduled for a cardiac catheterization. Which
assessment have to the nurse complete previous to this system?
A. Clients stage of hysteria
b. Ability to turn self in bed
c. Cardiac rhythm and coronary heart fee d. Allergies to iodine-based totally dealers
DIF: Remembering - ANS-ANS: D
Before the technique, the nurse ought to verify whether the purchaser has an allergic reaction
to iodine-containing arrangements, inclusive of seafood or local anesthetics. The assessment
medium used at some point of the technique is iodine primarily based. This hypersensitive
reaction can motive a lifestyles-threatening response, so it's far a excessive precedence.
Second, it's miles essential for the nurse to assess tension, mobility, and baseline cardiac
popularity.
10. A nurse cares for a patron who had a bronchoscopy 2 hours in the past. The client asks for
a drink of water. Which movement have to the nurse take subsequent?
A. Call the health practitioner and request a prescription for meals and water.
B. Provide the purchaser with ice chips rather than a drink of water.
C. Assess the clients gag reflex earlier than giving any food or water.
D. Let the consumer have a small sip to peer whether he or she will swallow. - ANS-ANS: C
The topical anesthetic used at some stage in the technique may have affected the clients gag
reflex. Before allowing the patron anything to consume or drink, the nurse must test for the go
back of this reflex.
DIF: Applying
10. After coaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the clients know-how. Which announcement by using the consumer shows a correct
know-how of the coaching?
A. I need to put on a snug-becoming shirt over the ICD.
B. I will keep away from sources of sturdy electromagnetic fields.
C. I must participate in a strenuous exercise software.
D. Now I can stop my antidysrhythmic medicinal drug. - ANS-ANS: B
The client being discharged with an ICD is advised to keep away from strong resources of
electromagnetic fields. Clients ought to keep away from tight clothing, which could purpose
infection over the ICD generator. The patron must be recommended to exercise however have
to no longer engage in strenuous sports that motive the coronary heart charge to meet or
exceed the ICD cutoff factor because the ICD can discharge inappropriately. The consumer
have to maintain all prescribed medicinal drugs.
- ANS-
- ANS-
- ANS-
1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses
the client to be disoriented to individual, area, and time. What motion by using the nurse is
exceptional?
A. Assess the clients pupillary responses.
B. Request a neurologic consultation.
C. Stop the infusion and call the provider.
D. Take and record a complete set of important symptoms. - ANS-ANS: C
A alternate in neurologic status in a customer receiving t-PA could indicate intracranial
hemorrhage. The nurse need to prevent the infusion and notify the provider at once. A complete
assessment, consisting of pupillary responses and critical symptoms, occurs subsequent. The
nurse might also or won't need to name a neurologist.
1. A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation.
Which manifestations should the nurse discover as unfavorable outcomes of this medication?
(Select all that practice.) a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Impaired judgment
e. Increased thirst - ANS-ANS: A, D
Varenicline (Chantix) has a black box caution declaring that the drug can reason manic conduct
and hallucinations. The nurse ought to check for changes in conduct and notion techniques,
consisting of impaired judgment and visible hallucinations. Tachycardia and increased thirst are
not detrimental outcomes of this remedy. Decreased cravings is a healing response to this
medicine.
DIF: Understanding
1. A nurse assesses a clients electrocardiograph tracing and observes that now not all QRS
complexes are preceded through a P wave. How need to the nurse interpret this statement?
A. The customer has hyperkalemia causing abnormal QRS complexes.
B. Ventricular tachycardia is overriding the normal atrial rhythm.
C. The clients chest leads aren't making sufficient contact with the pores and skin. D. Ventricular
and atrial depolarizations are initiated from distinctive sites.
. - ANS-ANS: D
,Normal rhythm suggests one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes with out a P wave suggest a
specific supply of initiation of depolarization. This finding on an electrocardiograph tracing is not
an illustration of hyperkalemia, ventricular tachycardia, or disconnection of leads
1. A nurse is being concerned for a customer with a records of renal insufficiency who's
scheduled for a cardiac catheterization. Which moves need to the nurse take previous to the
catheterization? (Select all that apply.) a. Assess for hypersensitive reactions to iodine.
B. Administer intravenous fluids.
C. Assess blood urea nitrogen (BUN) and creatinine outcomes.
D. Insert a Foley catheter.
E. Administer a prophylactic antibiotic.
F. Insert a valuable venous catheter. - ANS-ANS: A, B, C
If the customer has kidney ailment (as indicated by means of BUN and creatinine
consequences), fluids and Mucomyst may be given 12 to 24 hours earlier than the technique for
renal protection. The patron need to be assessed for allergies to iodine, which includes shellfish;
the evaluation medium used in the course of the catheterization contains iodine. A Foley
catheter and crucial venous catheter are not required for the manner and would most effective
boom the clients hazard for contamination. Prophylactic antibiotics are not administered
previous to a cardiac catheterization.
1. A nurse obtains the health history of a client who's lately identified with lung cancer and
identifies that the customer has a 60pack-yr smoking history. Which movement is maximum
crucial for the nurse to take when interviewing this purchaser?
A. Tell the patron that he wishes to give up smoking to forestall in addition cancer improvement.
B. Encourage the client to be absolutely sincere approximately each tobacco and marijuana
use. C. Maintain a nonjudgmental mindset to avoid causing the customer to sense guilty.
D. Avoid giving the consumer false hope regarding cancer treatment and analysis. - ANS-ANS:
C
Smoking history consists of the usage of cigarettes, cigars, pipe tobacco, marijuana, and
different managed substances. Because the customer might also have guilt or denial
approximately this habit, anticipate a nonjudgmental attitude at some point of the interview. This
will inspire the patron to be honest approximately the exposure. Ask the customer whether any
of those substances are used now or were used in the beyond. Assess whether the patron has
passive publicity to smoke within the home or workplace. If the customer smokes, ask for the
way long, what number of packs in step with day, and whether she or he has cease smoking
(and how long ago). Document the smoking history in p.C.-years (quantity of packs smoked
daily increased by way of the range of years the patron has smoked). Quitting smoking may not
prevent in addition cancer development. This declaration could be giving the patron false hope,
which need to be averted, however is not as critical as retaining a nonjudgmental attitude.
DIF: Applying
1. A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The
issuer prescribes zero.9% ordinary saline to infuse at a hundred twenty five mLhr for renal
,safety. The nurse obtains gravity tubing with a drip price of 15 dropsmL. At what charge
(dropsmin) must the nurse infuse the fluids? (Record your solution the usage of an entire
number, and rounding to the closest drop.) _____ drops - ANS-ANS:
31 drops
1.A 242-pound customer is being automatically ventilated. To save you lung damage, what
putting have to the nurse expect for tidal quantity? (Record your solution the use of an entire
wide variety.) ___ mL - ANS-ANS:
660 mL
A low tidal quantity of 6 mLkg is used to save you lung damage.
242 kilos = one hundred ten kg.
A hundred and ten kg x6 mLkg = 660 mL.
1.A nurse solutions a call light and reveals a consumer stressful, quick of breath, reporting chest
pain, and having a blood strain of 88/52 mm Hg on the cardiac reveal. What movement by
means of the nurse takes priority?
A. Assess the customers lung sounds.
B. Notify the Rapid Response Team.
C. Provide reassurance to the consumer.
D. Take a complete set of crucial signs and symptoms. - ANS-ANS: B
This consumer has manifestations of a pulmonary embolism, and the most vital action is to
inform the Rapid Response Team for quick analysis and remedy. The different movements are
appropriate also but are not the priority.
1.A nurse is worrying for five clients. For which customers might the nurse examine a high
danger for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to comparison dye the day gone by
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged guy with an exacerbation of bronchial asthma
d. Older customer who is 1-day submit hip alternative surgical procedure
e. Young overweight customer with a fractured femur - ANS-ANS: B, D, E
Conditions that location clients at higher risk of developing PE consist of prolonged immobility,
critical venous catheters, surgical procedure, obesity, advancing age, situations that growth
blood clotting, records of thromboembolism, smoking, pregnancy, estrogen remedy, coronary
heart failure, stroke, cancer (in particular lung or prostate), and trauma. A assessment dye
reaction and allergies pose no danger for PE.
10. A consumer in the cardiac stepdown unit reviews extreme, crushing chest pain observed
through nausea and vomiting. What action via the nurse takes priority?
A. Administer an aspirin.
B. Call for an electrocardiogram (ECG).
C. Maintain airway patency.
D. Notify the provider. - ANS-ANS: C
, Airway always is the concern. The different actions are vital in this situation as well, but the
nurse should live with the patron and ensure the airway stays patent (especially if vomiting
happens) at the same time as another individual calls the provider (or Rapid Response Team)
and enables getting an ECG performed. Aspirin will probably be administered, depending on the
vendors prescription and the clients modern-day medicines.
10. A nurse assesses a consumer who's scheduled for a cardiac catheterization. Which
assessment have to the nurse complete previous to this system?
A. Clients stage of hysteria
b. Ability to turn self in bed
c. Cardiac rhythm and coronary heart fee d. Allergies to iodine-based totally dealers
DIF: Remembering - ANS-ANS: D
Before the technique, the nurse ought to verify whether the purchaser has an allergic reaction
to iodine-containing arrangements, inclusive of seafood or local anesthetics. The assessment
medium used at some point of the technique is iodine primarily based. This hypersensitive
reaction can motive a lifestyles-threatening response, so it's far a excessive precedence.
Second, it's miles essential for the nurse to assess tension, mobility, and baseline cardiac
popularity.
10. A nurse cares for a patron who had a bronchoscopy 2 hours in the past. The client asks for
a drink of water. Which movement have to the nurse take subsequent?
A. Call the health practitioner and request a prescription for meals and water.
B. Provide the purchaser with ice chips rather than a drink of water.
C. Assess the clients gag reflex earlier than giving any food or water.
D. Let the consumer have a small sip to peer whether he or she will swallow. - ANS-ANS: C
The topical anesthetic used at some stage in the technique may have affected the clients gag
reflex. Before allowing the patron anything to consume or drink, the nurse must test for the go
back of this reflex.
DIF: Applying
10. After coaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the clients know-how. Which announcement by using the consumer shows a correct
know-how of the coaching?
A. I need to put on a snug-becoming shirt over the ICD.
B. I will keep away from sources of sturdy electromagnetic fields.
C. I must participate in a strenuous exercise software.
D. Now I can stop my antidysrhythmic medicinal drug. - ANS-ANS: B
The client being discharged with an ICD is advised to keep away from strong resources of
electromagnetic fields. Clients ought to keep away from tight clothing, which could purpose
infection over the ICD generator. The patron must be recommended to exercise however have
to no longer engage in strenuous sports that motive the coronary heart charge to meet or
exceed the ICD cutoff factor because the ICD can discharge inappropriately. The consumer
have to maintain all prescribed medicinal drugs.
