Lewis\\\'s Medical Surgical Nursing: Assessment and M Study guides, Class notes & Summaries

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. an RBC count of 4,500,000/L. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L). - -ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the...

After assessment of a patient with *pneumonia*, the nurse identifies a nursing diagnosis of *ineffective airway clearance*. Which assessment data best supports this diagnosis? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85% - -a. Weak cough effort The weak, *nonproductive cough* indicates that the patient is *unable to clear the airway* effectively. -The nurse assesses the chest of a patient with pneumococcal...

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85% - -ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses ...

1. During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical p...

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for the past 8 hours. d. There is prolonged skin tenting over the sternum. - -ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. Thi...

A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring. - -ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would be...

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium level of 120 mg/dL c. Reported weight gain of 2.2 lb (1 kg) d. Urinary output of 280 mL during past 8 hours - -ANS: B Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia c...

The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see FIRST? - -a. 22-year-old with persistent red-brown vaginal drainage 3 days after having balloon thermotherapy b. 42-year-old with secondary amenorrhea who says that her last menstrual cycle was 3 months ago c. 35-year-old with heavy spotting after having a progestin-containing IUD (Mirena) inserted a month ago D. 19-year-old with menorrhagia who has been using superabsorbe...

Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 11th Edition TESTBANK Chapter 1. Professional Nursing MULTIPLE CHOICE 1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patients input. The patient states, How is this different from what the doctor does? Which response would be most appropriate for the nurse to make? a. The role of the nurse is to administer medic...

Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 11th Edition TESTBANK NEW UPDATE 2022