Acute 2 exam 2 questions
A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure? A.Pulmonary edema B.Hypovolemic shock C.Pulmonary embolus D.Opioid analgesic overdose
D
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A.24-year-old male admitted with blunt chest trauma and aspiration B.56-year-old male with a history of alcohol abuse and chronic pancreatitis C.72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D.82-year-old female on antibiotics for pneumonia
A
A nurse is teaching a group of patients about Metabolic syndrome. Which assessment features are associated with the syndrome? (Select all that apply.) A.Male waist circumference 44 inches B.Fasting blood glucose 66 mg/dL C.Triglyceride value of 162 mg/dL D.Blood pressure 135/85 E.Patient is taking blood pressure medication
A, C, D, E
A patient has experienced a stroke in the left cerebral hemisphere. What clinical presentation does the nurse expect? (Select all that apply.) A.Aphasia B.Decreased proprioception C.Disoriented to time and place D.Agraphia E.Difficulty with math calculation
A, D, E
A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? A."I should limit my alcohol consumption." B."I should eat more green leafy vegetables like spinach." C."I should take the medication at the same time every day." D."I should make a doctor's appointment for weekly blood draws."
B
A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? A.Loss of vision B.Brain stem herniation C.Intense headache D.Projectile vomiting
B
A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A.Notify the health care provider. B.Place the patient in a sitting position. C.Check the patient for fecal impaction. D.Check the urinary catheter for kinks or obstruction.
B
Two days later, the patient's sacral area appears to have an abrasion where the skin is not intact. What is your interpretation of this finding? A.Stage I pressure injury B.Stage II pressure injury C.Stage III pressure injury D.Stage IV pressure injury
B
When caring for a patient having a hypoglycemic episode, the nurse knows which symptom requires immediate intervention? A.Hunger B.Confusion C.Headache D.Tachycardia
B
The nurse is teaching a patient with type 1 diabetes about exercise. The nurse understands the patient should avoid exercise during what time? A.During colder months B.When serum glucose is less than 150 C.When ketones are present in the urine D.When emotional stressors are high for the patient
C
The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? A.Increased pupil size B.Nausea and vomiting C.Agitation and confusion D.Elevated blood pressure
C
Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? A. No action is necessary at this time. B. Notify the physician of a possible wound infection. C. Clean the wound and reassess for presence of infection. D. Culture the wound and anticipate an order for antibiotics.
C
An older adult patient with a long history of congestive heart failure is being treated for a pressure ulcer over the coccyx that is 4 cm wide and 5 cm long, with eschar present. Which technique does the nurse anticipate will be used to remove the necrotic tissue? A. Surgical removal B .Biologic dressing C. Continuous dry gauze dressing D. Dressings along with a topical enzyme preparation
D
