Adult Health Exam 2

Which of the following is an effective strategy to prevent ventilator-associated pneumonia (VAP)

providing oral care with an antiseptic mouthwash

Which of the following is a priority nursing assessment for a patient pneumonia?

respiratory rate

The home care nurse visits a 79-year-old client who was discharged from the hospital one week ago for treatment of heart failure. The client tells the nurse that the exercise regimen of walking three times weekly was started but feels extremely fatigued the day after walking. The client has avoided walking this week because of feeling so tired. The nurse gathers additional data and documents the following.

1.) advise the client to slow down on exercising 2.) tolerance to increased activity needs to be built up and takes time

The nurse should assess the client with left-sided heart failure for which findings? select all that apply

A.) dyspnea C.) crackles E.) oliguria F.) decreased oxygen saturation levels

Which of the following nursing interventions is appropriate for a patient with pneumonia experiencing fever and chills?

Administering antipyretic medication as ordered

Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus Rythm with a rate of 72 beats/min to atrial fibrillation with a ventricular response rate of 100 beats/min. In what order from first to last should the nurse perform these interventions? Select all that apply

B.) assit the client into bed C.) initiate IV access D.) obtain a stat 12-lead electrocardiogram

The nurse observes the cardiac rhythm for a client who is being admitted with a myocardial infarction. What should the nurse do first?

Check for a pulse

which are indications that the client with a history of left-sided heart failure is developing pulmonary edema? select all that apply

D.) course crackles E.) tachycardia

Which of the following is a common treatment for COPD?

Oxygen therapy

Which of the following is a priority nursing assessment for a patient with COPD?

Pulse Oximetry

Which of the following is a common symptom of chronic obstructive pulmonary disease (COPD)

Shortness of breath

Which of the following nursing interventions is appropriate for a patient with COPD?

Teaching the patient to use pursed lip breathing techniques

a client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin. The expected outcome of this drug is to

prevent thrombus formation.

Which of the following nursing interventions is appropriate for a patient with COPD experiencing dyspnea?

administering the supplemental oxygen as ordered

which of the following is a common treatment for pneumonia?

antibiotics

The nurse is admitting an older adult to the hospital. The echocardiogram reported revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

assess respiratory status

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first

assess the client's orientation and vital signs

Which of the following nursing interventions is appropriate for a patient with pneumonia?

assisting the patient with ambulation as tolerated

Which of the following is a type of COPD

bronchitis

Which of the following is a symptom of pneumonia?

chest pain

Which of the following nursing interventions is important for preventing complications in a patient with pneumonia?

encouraging the patient to cough and deep breathe

Which of the following is an important nursing intervention to promote airway clearance in a patient with COPD?

encouraging the patient to sit upright and use a coughing technique.

An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker?

maintain cardiac conduction stability

Which of the following is a potential complication of pneumonia?

pleural effusion

The nurse teaches a client with heart failure to take oral furosemide in the morning, the Primary reason for this is to prevent

sleep disturbances during the night

which of the following is a risk factor for developing pneumonia?

smoking

Which of the following is an important nursing intervention for preventing the spread of pneumonia?

wearing PPE when providing care