Pass point/ Quiz questions Adult Exam I

The nurse is preparing to administer lorazepam 1 mg I.V. for a client with anxiety. The available dose is 2 mg/2 ml vial. How many milliliters of medication will the nurse ask another nurse to witness as a waste? Record your answer as a whole number.

1

The nurse is caring for a patient recovering from a coronary angioplasty with stent placement. Which intervention is a priority for the patient at this time? 1.securing chest tubes to bedding 2.maintaining leg extension on the affected side 3.discontinuing intravenous lines when taking oral fluids 4.treating chest pain with intravenous morphine as needed

2.maintaining leg extension on the affected side

Normal HR range

60-100 bpm

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube?

Auscultation indicates bowel sounds in all four quadrants.

The nurse assess a patient HR as being 50 beats per minute. How should the nurse document this finding

Bradycardia

During the physical exam of a pt abdomen the nurse auscultates a blowing sound over the aorta. How should the nurse document this finding?

Bruit

Cardiac Output (CO) is calculated using the following formula:

CO= Heart Rate x Stroke Volume

During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What should the nurse do?

Communicate the discrepancy to the surgical team immediately.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first?

Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

A patient who is hemorrhaging has decreased preload. What physiologic effect should the nurse expect to occur with this patient

Decreased CO

A patient has had bowel surgery. The nurse is assessing the patient's abdomen and knows that the best indicator of intestinal activity is:

Detection of bowel sounds upon auscultation

A patient having surgery is at risk for infection if which additional factor is present?

Diabetes Mellitus

The heart wall consists of three layers of tissue. They include all of the following:

Epicardium Myocardium Endocardium

An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first?

Establish an airway

A patients is being admitted for a low platelet count. What subjective data should the nurse expect to assess that is consistent with this data

Excessive bruising

The nurse is caring for a patient with acute coronary syndrome. Which nursing diagnosis should be the priority for this patient? 1.Anxiety related to unknown outcome of disorder 2.Decreased Cardiac Output related to myocardial ischemia 3.Ineffective Health Maintenance related to lack of knowledge about coronary heart disease 4.Ineffective Tissue Perfusion: Cardiopulmonary related to underlying coronary heart disease

Ineffective Tissue Perfusion: Cardiopulmonary related to underlying coronary heart disease

The nurse is preparing to assess a pt apical impulse, which anatomical location should the nurse use to make this assessment,

Left mid clavicular line, 5th intercostal space

An important nursing intervention to complete following a positron emission tomography (PET) scan is to

Monitor the patient's blood glucose levels

A patient has been admitted with severe leg pain. The limb is cyanosis, cool to the touch, and peripheral pulses are absent. What should the nurse do first after this assessment

Notify a doctor

A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse?

Notify the surgeon as soon as possible.

The nurse is preparing to assess a patient who is experiencing chest pain. Which question should the nurse ask to learn more information about intensity of pain?

On a scale of 0 (no pain) to 10 (worst pain) what number is your pain?

The nurse is preparing to assess a patients carotid arteries. Which techniques should the nurse use for this assessment. Select all that apply

Palpate for pulse rate Inspect for pulsations Auscultate rhythm

The first chamber in the heart that blood enters is the:

Right Atrium

When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, which laboratory value may result in cancellation of the surgery?

Serum potassium 2.9 mEq/L

Which change in the integumentary system is associated with normal aging?

Subcutaneous fat and extracellular water decrease.

The nurse determines that an older patient would benefit from interventions to address peripheral vascular resistance. What manifestation did the nurse assess in this patient? Select all that apply

Sunken eyeballs Elevated BP

Which sentence correctly describes the prone position?

The body is facedown.

When a patient is admitted to the post-anesthetic care unit (PACU), the nurse should first assess the patient's:

airway and gas exchange

A client's face, neck, and chest have been burned in a fire 1 hour ago. What is the nurse's priority assessment at this time?

airway obstruction

1st degree AV block s/s

asymptomatic

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it is slightly concave. Additional assessment should proceed in which order?

auscultation, percussion, and palpation

An older adult reports being cold in the room even though the thermostat is set at 75°F (24°C). The nurse can tell the client that older adults may feel cold for which reason? Older adults have:

decreased ability to thermoregulate.

The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client?

buccal mucosa

3rd degree block treatment

complete; usually requires pacemaker (nothing transferring from top to bottom of heart)

Which component of a client's medical record is the major source of subjective data about the client's health status?

health history

A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client?

inelastic skin turgor is a normal part of aging

During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?

objective

2nd degree AV treatment

pharmacologic treatment (pace maker)

A nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

tradition and ethnic factors

A patient is complaining of new onset calf and foot pain. The nurse notes that the leg below the knee is cool, pale, and dorsalis pedis and posterior tibial pulses are absent. What should the nurse do first to help this patient? 1. Notify the healthcare provider. 2.Prepare to initiate heparin therapy. 3. Position the leg flat, supported in anatomic position. 4. Place a cradle over the leg to prevent pressure from bedding.

1. Notify the healthcare provider. Manifestations of acute arterial occlusion include cool or cold skin, pain, and pulselessness distal to the blockage. This is an emergency and the healthcare provider should be contacted immediately.

The nurse recognizes that a patient has developed second-degree AV block, type II (Mobitz II). Which action should the nurse take at this time? 1.Record the finding in the chart. 2.Places the patient in Fowler's position. 3.Prepare for temporary pacemaker insertion. 4.Administer a Class IB antidysrhythmic drug.

3.Prepare for temporary pacemaker insertion.

A patient admitted 24 hours previously with heart failure has lost 1 kg (2.2 lb) of weight, has a heart rate of 88 which was 105 on admission, and now has crackles only in the bases of the lungs. How should the nurse interpret these assessment findings? 1.More aggressive treatment is needed. 2.The patient's condition is unchanged from admission. 3.The treatment regimen is achieving the desired effect. 4.No further treatment is required at this time as the failure has resolved.

3.The treatment regimen is achieving the desired effect.

The nurse is caring for a patient with stable angina. Which assessment finding would be consistent with this medical diagnosis? 1.persistent ECG changes 2.increasing nocturnal pain 3.correlation between activity level and pain 4.evidence of impaired cardiac output such as weak peripheral pulses

3.correlation between activity level and pain

Auscultation of an apical pulse lateral to the mid-clavicular line or below the fifth left intercostal space is an abnormal finding. T/F

False

A patients lab values indicate a low RBC. What subjective data should the nurse expect to assess that is consistent with that data

Fatigue