Adult Health 1 Exam 2
The nurse is preparing to change a patient's sternal dressing. What action by the nurse is most important?
Perform hand hygiene.
A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the patient's respiratory status.
A nurse assesses a patient's electrocardiogram (ECG) and observes the reading shown below: How would the nurse document this patient's ECG strip?
Sinus rhythm with premature ventricular contractions (PVCs)
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service?
African-American churches
A nurse assesses a patient after administering isosorbide mononitrate (Imdur). The patient reports a headache. What action would the nurse take?
Administer PRN acetaminophen.
A patient has hypertension and high-risk factors for cardiovascular disease. The patient is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?
Assist in finding one change the patient can control.
The nurse is evaluating a 3-day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet?
Baked chicken breast, broccoli, tomatoes
A nurse is caring for a patient who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which provider order does the nurse implement first?
Connect the patient to a cardiac monitor.
A nurse is caring for an older adult patient who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?
Dangle the patient on the bedside before ambulating.
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
A nurse is caring for a patient who has the following laboratory results: potassium 3.4 mEq/L (3.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
Depth of respirations
A nurse is assessing patients on a medical-surgical unit. Which patient is at risk for hypokalemia?
Patient with pancreatitis who has continuous nasogastric suctioning
The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning?
Triglycerides: 198 mg/dL
A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
"I must stop halfway up the stairs to catch my breath."
A nurse teaches a patient who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this patient's teaching?
"Minimize or abstain from caffeine."
A nurse cares for a patient with right-sided heart failure. The patient asks, "Why do I need to weigh myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid."
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.)
Hypernatremia—Hyperaldosteronism Hypocalcemia—Diarrhea Hyperkalemia—Salt substitutes
A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?
"Avoid straining while having a bowel movement."
A nurse is assessing a patient with peripheral artery disease (PAD). The patient states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
"Could you walk further than that a few months ago?"
A nurse teaches a patient who is prescribed digoxin (Lanoxin) therapy. Which statement would the nurse include in this patient's teaching?
"Do not take this medication within 1 hour of taking an antacid."
A nurse teaches a patient with heart failure about energy conservation. Which statement would the nurse include in this patient's teaching?
"Gather everything you need for a chore before you begin."
A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self-management activities?
"I can use a heating pad on my legs if it's set on low."
After teaching a patient who is being treated for dehydration, a nurse assesses the patient's understanding. Which statement indicates that the patient correctly understood the teaching?
"I will weigh myself each morning before I eat or drink."
After teaching a patient with congestive heart failure (CHF), the nurse assesses the patient's understanding. Which patient statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)
"I'll read the nutritional labels on food items for salt content." "Substituting fresh vegetables for canned ones will lower my salt intake." "I will eat oatmeal for breakfast instead of ham and eggs."
A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
"Most people with hypertension do not have symptoms."
A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure?
"My shoes fit really tight lately."
The nurse asks a patient who has experienced ventricular dysrhythmias about substance abuse. The patient asks, "Why do you want to know if I use cocaine?" What is the nurse's best response?
"Patients who use cocaine are at risk for fatal dysrhythmias."
A patient with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?
"The best source is fish, but pills have benefits too."
A patient received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The patient's spouse asks why the patient needs this medication. What response by the nurse is best?
"The heparin keeps that artery from getting blocked again."
A patient is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the patient to the bathroom and notes the patient's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
Allow continued bathroom privileges.
A nurse cares for a patient who is on a cardiac monitor. The monitor displayed the rhythm shown below: What action would the nurse take first?
Assess airway, breathing, and circulation.
An older adult is on cardiac monitoring after a myocardial infarction. The patient shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm.
While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?
Assess for symptoms of left-sided heart failure.
The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider?
Furosemide (Lasix)/potassium: 2.1 mEq/L
After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the patient's understanding. Which food choice for lunch indicates that the patient correctly understood the teaching?
Grilled chicken breast with glazed carrots
A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention would the nurse perform prior to defibrillating this patient?
Ensure that everyone is clear of contact with the patient and the bed.
A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)
Increased pulse rate Skeletal muscle weakness Distended neck veins.
The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, what action would the nurse take next?
Initiate cardiopulmonary resuscitation (CPR).
After administering newly prescribed captopril (Capoten) to a patient with heart failure, the nurse implements interventions to decrease complications. Which priority intervention would the nurse implement for this patient?
Instruct the patient to ask for assistance when rising from bed.
A telemetry nurse assesses a patient who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next?
Level of consciousness
A patient in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
Maintain airway patency.
A nurse assesses a patient with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
Midsternal chest pain
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
Palpating both carotid arteries at the same time
A nurse is caring for four patients. Which one would the nurse see first?
Patient who had a first dose of captopril (Capoten) and needs to use the bathroom
A patient had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
Poor peripheral pulses and cool skin
A nurse cares for a patient who has a serum potassium of 7.5 mEq/L (7.5 mmol/L) and is exhibiting cardiovascular changes. Which prescription will the nurse implement first?
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
A nurse is assessing a patient with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.)
Pulmonary crackles Cough that worsens at night Confusion, restlessness
After teaching a patient to increase dietary potassium intake, a nurse assesses the patient's understanding. Which dietary meal selection indicates that the patient correctly understands the teaching?
Sausage, one slice of whole-wheat toast, half cup of raisins (120 gm), and a glass of milk
A nurse cares for a patient with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions would the nurse implement to address this patient's concerns?
Schedule periods of exercise and rest during the day.
A nurse administers prescribed adenosine (Adenocard) to a patient. Which response would the nurse assess for as the expected therapeutic response?
Short period of asystole
A nurse assesses a patient with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition?
Speech alterations
A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient's medication administration record to prevent a common complication of this condition?
Warfarin (Coumadin)
