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NURS401 Exam: Questions With Correct Solutions (Expert Verified)
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NURS401 Exam: Questions With Correct Solutions (Expert Verified)
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NURS401 Exam: Questions With Correct Solutions(Expert Verified)
A client is diagnosed with left-sided heart failure. Which assessment findings
will the nurse expect the client to have? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
C. Breathlessness
D. Ascites
E. Tachypnea Right Ans - B. crackles in both lungs, C. breathlessness, E.
tachypnea
Rationale: Clients with left-sided heart failure will exhibit symptoms such as
fatigue, dyspnea, or breathlessness, and crackles on auscultation of breath
sounds. Peripheral edema and ascites are associated with right-sided heart
failure.
A client has been taking furosemide (Lasix) and valsartan (Diovan) for the
past year. The hospital laboratory notifies the nurse that the client's serum
potassium level is 6.2 mEq/L. What is the nurse's best action at this time?
A. Assess the client's oxygen saturation level
B. Ask the laboratory to retest the potassium level
C. Give potassium as an IV insertion
D. Check the client's serum creatinine Right Ans - D. Check the client's
serum creatinine.
Rationale: Clients who are hyperkalemic may also be in renal failure. The
client's serum creatinine should be reviewed to determine if it is greater than
1.8 mg/dL, at which time the health care provider should be notified before
administering any supplemental potassium.
An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic
heart failure is admitted to the ED with an apical pulse of 48. A family member
states that the client has reported blurred vision and loss of appetite for 2
weeks. What is the nurse's first action?
A. Call the ED physician immediately
B. Draw a serum digoxin level
C. Assess for signs of hypokalemia
D. Establish the client's airway Right Ans - B. Draw a serum digoxin level
, Rationale: The clinical manifestations of digoxin toxicity are often vague and
nonspecific and include anorexia, fatigue, blurred vision, and changes in
mental status, especially in older adults. Older adults are more likely than
other patients to become toxic because of decreased renal excretion.
A middle-aged man is admitted to the cardiac unit after reports of a severe
headache and flushing of the face. He is diagnosed with severe hypertension.
The patient is alert and oriented. BP = 192/104, HR = 88. You are the RN
assigned to his care. There is an unlicensed nurse technician working with
you.
1. What assessment data will you perform upon his arrival to the unit? why?
2. The cardiologist prescribes IV fluids, hourly BP checks, BP medication, and
oxygen at 2 L/min via nasal cannula. What part of the patient's care will you
delegate to the unlicensed nurse technician? What information will you
communicate upon delegation?
3. What interventions will you implement to ensure this patient's safety?
4. The patient's wife is very concerned about her husband returning to work
as owner of a roofing company. What education will you provide the patient
and his wife at this time? With what health care team members w Right
Ans - 1. Assess all VS, specifically BP, and conduct a head to toe assessment. VS
should be taken to continue observing the pt's condition (specifically HTN)
and trended to determine if treatment and interventions are working. During
the physical assessment, you will specifically need to listen to the heart for the
presence or absence of murmurs or other abnormal heart sounds and perform
a basic neurological assessment to determine the pt's baseline orientation.
2. Can delegate: hourly BP checks, with understanding that you must follow all
Nurse Practice Acts related to appropriate delegation.
Communicate: task that is to be performed and the method by which it should
be (manual vs automated). Also clarify that you need the findings reported
back to you hourly.
Follow up hourly to obtain report of the vitals so you can make appropriate
nursing decisions
3. Safety precautions; if need for invasive diagnostic testing, determine if there
is iodine-based contrast media allergies; report dysrhythmias immediately;
continually assess pt's report of pain, especially when pt's report is
descriptive of angina or MI; teach pt safety precautions regarding calling for
assistance if pt needs to ambulate to the bathroom b/c syncope can be related
to severe HTN
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