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Adult Nursing F20
N125 Exam 2
| Question | Answer |
|---|---|
| A client has a history of renal calculi. Which statement by the client indicates a good understanding of preventive measures? | “I know I should drink at least 3 to 4 liters of fluid every day.” Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin does not cause a stone. Antibiotics neither prevent nor treat a stone. |
| A client has been admitted from a nursing home for a workup to determine the cause of several recent falls. What intervention by the nurse takes priority? | Obtain a clean catch or catheterized urine specimen. Alt. all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often UTI symptoms in older adults are atypical, & a UTI may present w/ new onset of confusion |
| A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement? | Discussing w/the client his/her acceptance of the disease. Some people on dialysis retreat into complete or partial denial of the disease & the need for treatment. They may deny the need for dialysis &/or may not adhere to drug therapy and diet restricti |
| A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? | A chicken leg, one slice of bread with butter, & steamed carrots. Clients on restricted Na+ diets generally shd avoid processed, smoked, & pickled foods &those w/ sauces &other condiments. Foods lowest in Na+ include fish, poultry, & fresh produce. |
| A client is admitted with a 3-day history of vomiting and diarrhea. The client’s vital signs are blood pressure, 85/60 mm Hg; and heart rate, 118 beats/min. Which intervention by the nurse takes priority? | Start an IV of normal saline as ordered. The nurse shld first initiate the ordered IV fluids. Obtaining cultures will help identify a possible cause of the client’s sx & shd be done quickly after the IV has been started. . |
| A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe? | When I feel lightheaded, I will drink a full glass of water.” Feeling lightheaded/dizzy is an indication of ↓ BP & poor perfusion. Mild dehydration can cause these problems & ↑ fluid intake at the first sign of dehydration may prevent it from becoming wo |
| A client’s urine specific gravity is 1.040. Which action by the nurse is best? | ↑ the client’s fluid intake. Normal specific gravity for urine is 1.005 to 1.030. ↑ specific gravity can occur w/ dehydration, ↓ kidney blood flow (often bec of dehydration), & the presence of antidiuretic hormone (ADH). ↑ the pt’s fluid intake wld be |
| The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? | Using sterile technique when hooking up dialysate bags. To prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags |
| The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client? | “Read food labels to determine sodium content.” Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia. |
| Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated? | The client states that he feels lightheaded when he gets out of bed or stands up. Orthostatic or postural hypotension can be caused by or worsened by dehydration. |
| A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse’s best response? | “Weight is the best indication that you are gaining or losing fluid.” Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. |
| A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? | ↓ BP, ↓ in cardiac output Consistently elevated HRs initially cause BP & cardiac output to ↑. However, ventricular filling time, cardiac output, & BP eventually ↓ . As cardiac output and blood pressure decrease, urine output will fall. |
| A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse’s priority intervention? | Assess respiratory status. Assessment of resp & oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes & inserting a catheter are important but do not take priority over assessing resp status. |
| A client who is scheduled for an echocardiography today asks why this test is being performed. What is the nurse’s best response? | “This procedure is a noninvasive way to assess the structure of the heart.” Echocardiography is performed to assess the structure & function of the heart, esp the valves & wall motion. |
| A client with heart failure is experiencing acute shortness of breath. What is the nurse’s priority action? | Place the client in a high Fowler’s position. Placing a client in a high Fowler’s position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation |
| When caring for a patient who has just had a cardiac catheterization, which nursing intervention can the nurse delegate to an unlicensed assistive personnel (UAP)? | Connect cardiac monitoring and initiate vital sign monitoring. Connecting a patient to a cardiac monitor and performing vital signs is in the scope of practice for an UAP. |
| The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client’s activity? | Systolic blood pressure changes from 136-96 mm hg. BP changes <20mmhg during/after activity means poor cardiac tolerance of activity. Signifcnt ↓ >20 mmhg BP is esp ominous bec it indicates inability of the left ventricle to maintain sufficient card/outp |
| Match the following complexes to their associated cardiac function. | PR segment - The time required for the impulse to travel thr the AV node just be4 ventricular depolarization ST segment - Early ventricular repolarization QRS complex - Ventricular depolarization P wave - atrial depolarization |
| When reviewing a client’s laboratory results, which findings alert the nurse to the possibility of atherosclerosis? (Select all that apply.) | Total cholesterol of 280 mg/dL, Triglycerides of 200 mg/dL, Low-density cholesterol of 160 mg/dL. A lipid panel is often used to screen for cardiovascular risk. |
| A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the nurse’s best response? | “It is a rushing sound that blood makes moving through narrow places.” Murmurs reflect turbulent blood flow thr normal/abnormal valves. The significance of a murmur depends on its cause. Some murmurs are asso w/a healthy heart that ejects blood quickly & |
Created by:
rferris77
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