A nurse is caring for a 71-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) who is experiencing cardiac ischemia with increased shortness of breath. The MOST appropriate goal of oxygen therapy for this patient would be to: correct answers Maintain oxygen saturatio...
PCCN Review || with 100% Errorless Answers.
A nurse is caring for a 71-year-old female patient with end-stage chronic obstructive pulmonary
disease (COPD) who is experiencing cardiac ischemia with increased shortness of breath. The
MOST appropriate goal of oxygen therapy for this patient would be to: correct answers Maintain
oxygen saturations between 90% and 92%
Feedback
Maintaining oxygen saturations between 90% and 92% will serve the purpose of providing
enough oxygen to relieve cardiac ischemia while reducing the risk of respiratory depression in a
patient with COPD.
Laboratory studies from a 22-year-old male client with Type I diabetes mellitus are evaluated
during an admission for severe pneumonia. Which of the following laboratory results should the
nurse report to the physician? correct answers Glycosylated hemoglobin (HbA1c), 9.8%
Feedback
Glycosylated hemoglobin measures the average blood sugar levels over a 2 to 3 month time
period. Clients with previously diagnosed diabetes mellitus should aim to keep their HbA1c
levels below 7%.CONTENT AREA: Clinical Judgement:
Endocrine/Hematology/Neurology/GI/Renal
The nurse is assessing a 68 year old female patient with a history of chronic obstructive
pulmonary disease (COPD). The patient presents with complaints of recent confusion, increased
fatigue, and syncopal episodes when walking. The nurse assesses S3 and S4 sounds on
auscultation, jugular vein distention, and +3 pitting edema of the ankles and feet. Which of the
following complications of COPD does the nurse suspect the patient is most likely experiencing?
correct answers Cor pulmonale
Feedback
The nurse should recognize that a history of COPD together with the signs and symptoms listed
here are suggestive of cor pulmonale. The patient requires further workup to confirm this
diagnosis.
A 42-year-old male with Marfan syndrome and complaint of dizziness is admitted to the
telemetry unit for monitoring. Which of the following accompanying symptoms may indicate the
need for immediate surgical attention? correct answers A. Cough with vocal hoarseness
Feedback
Patients diagnosed with Marfan syndrome are at higher risk for aortic aneurysms. Changes in
vocal quality accompanied by a cough or dysphagia (difficulty swallowing) may indicate that a
thoracic aortic aneurysm is becoming more enlarged.
The nurse is assessing a 74 year old female patient who has presented with the following
symptoms: cool, clammy skin; faint, irregular peripheral pulses, and +3 pitting edema in her
bilateral lower extremities. Her partner tells the nurse the patient has a history of heart failure
with a recent LVEF of 20%, as well as type 2 diabetes. The patient's HR is 132, BP is 79/48, and
blood glucose is 349. Which of the following conditions does the nurse suspect? correct answers
Cardiogenic shock
,Feedback
The nurse should identify that cardiogenic shock is an emergency that has extremely high
mortality rates without timely intervention. The patient's history of heart failure together with her
acute symptoms of weak pulses, edema, and hypotension all point to cardiogenic shock.
The nurse is caring for a patient with stage 5 chronic kidney disease who normally receives
hemodialysis three times a week on Monday, Wednesday, and Friday. It is now Sunday and the
patient states they have missed their last two dialysis sessions. The patient is complaining of
shortness of breath and fatigue, and their labs show a creatinine of 3.9 and potassium of 6.8.
What is the BEST treatment for this patient ? correct answers Urgent hemodialysis
Feedback
The nurse should recognize that dialysis is the best option for this patient since they are already a
regular dialysis patient and are a likely candidate to receive urgent dialysis due to their missed
dialysis sessions, shortness of breath, and critical potassium level.
A 17-year-old male client is recovering from idiopathic infective endocarditis. The nurse should
include which of the following teaching points in the discharge care plan for this client? correct
answers Taking prophylactic antibiotics before dental procedures
Feedback
Client with a history of infective endocarditis should take prophylactic antibiotics before dental
procedures and some surgical procedures.
The nurse is caring for a 21 year old female who is being treated with IV magnesium for pre-
eclampsia. Upon assessment, the nurse notes that the patient's skin is flushed, her blood pressure
is 88/56, and her respiratory rate is 12. The nurse checks the patient's magnesium level and finds
that it is 7.2 mg/dL. Which of the following actions does the nurse anticipate taking next? correct
answers Administering intravenous calcium gluconate
Feedback
The nurse should identify that the signs and symptoms here are reflective of a critically high
magnesium level, reflected by the lab level of 7.2 mg/dL, and that the correct treatment is an
infusion of calcium gluconate.
A 22-year-old male patient is admitted for observation following a linear temporal skull fracture
from a skiing accident. Upon admission at 2 pm, the patient was alert and oriented, and reports
that he "passed out for a second" immediately after his accident. At 4 pm, the nurse notes that the
patient's Glasgow Coma Scale (GCS) is 8. The nurse should: correct answers Prepare the patient
for burr hole placement with clot evacuation
Feedback
This patient is exhibiting classic signs and symptoms of an epidural hematoma. Surgical
intervention to remove the hematoma and relieve pressure on the brain should be performed as
soon as possible.
A 71-year-old female patient is admitted after evaluation in the emergency department (ED) for
suspected coronary syndrome involving the inferior wall. Which of the following changes would
the nurse anticipate seeing on a 12-lead ECG for an inferior wall myocardial infarction (MI)?
correct answers ST elevation, Q waves, and inverted T waves in leads II, III, and aVF
, Feedback
Acute coronary syndromes involving the inferior cardiac wall will most often manifest as ST
elevation and inverted T waves in leads II, III, and aVF. Q waves may appear during the acute
phases of the syndrome, or may appear as an infarction heals (more common).
The nurse has a 32 year old female patient with a diagnosis of major depressive disorder. The
patient tells the nurse that she wishes every night that she could go to sleep and never wake up.
She also tells the nurse that she has been thinking that it would be easy to take a whole bottle of
Tylenol "to end my pain forever." What is the MOST appropriate intervention for the nurse to
take? correct answers Ensure that the patient's physical environment is safe and free of objects
that could be used to harm herself
Feedback
The nurse should identify that the most important thing when working with a patient who is
expressing suicidal ideology is patient safety; this begins with the patient's physical environment
and ensuring that there is nothing that the patient can access that can be used to harm themselves.
A telemetry nurse is caring for a 59-year-old male patient who is being evaluated for non-
specific cardiac symptoms. Just after the nurse arrives in the patient's room to administer the
morning medications, the patient loses consciousness. The cardiac monitor reveals third-degree
AV heart block with ventricular escape beats at 38 beats per minute (bpm). The nurse should:
correct answers Prepare to initiate transcutaneous pacing
Feedback
Third-degree heart block with a slow ventricular escape rhythm that is not sufficient to keep a
patient alert should be immediately addressed by transcutaneous pacing to provide adequate
brain perfusion (and perfusion of other organs). Medications should be administered per ACLS
protocols or as directed by a health care practitioner.
The nurse is educating a 24 year old patient who has been diagnosed with diabetic gastroparesis.
The nurse teaches the patient that which of the following lifestyle modifications will be helpful
and appropriate? correct answers Ensure well-controlled blood glucose levels
Feedback
The nurse should know that ensuring well-controlled blood glucose levels is one of the most
helpful strategies for diabetic gastroparesis. The other three strategies listed are all
contraindicated and can make the condition worse.
The nurse is providing discharge education to a 47 year old male patient who was admitted for
acute alcohol withdrawal. The patient tells the nurse that his intent is to pursue outpatient
treatment for alcohol use disorder. Which of the following teaching points is appropriate for this
patient? correct answers Eat a diet rich in leafy greens, legumes, citrus, and whole grains
Feedback
The nurse should recall that patients who chronically abuse alcohol are usually deficient in
folate, and the listed foods are rich in folate and will help the patient replenish their nutrients.
A nurse is caring for a patient with a recent history of an ischemic (embolic) stroke. To evaluate
the patient's current status, the nurse uses the National Institutes of Health Stroke Scale (NIHSS).
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