Assessment findings for a patient with CHF include severe dyspnea, orthopnea , spao2 84% , bilateral crackles and lower extremity edema. The nurse would call the MD and question which orders....(SATA)
A. Ambulate 4 times a day B. Regular diet C. Compression stockings D. Daily weights E. 0.9% nacl ...
Nur 243 Test Two Questions and
Complete Solutions
Assessment findings for a patient with CHF include severe dyspnea, orthopnea , spao2
84% , bilateral crackles and lower extremity edema. The nurse would call the MD and
question which orders....(SATA)
A. Ambulate 4 times a day
B. Regular diet
C. Compression stockings
D. Daily weights
E. 0.9% nacl IV at 200ml/hr ✅a.
B.
E.
While assessing an elderly patient, the nurse finds the urinary collection bag lying in the
bed next to the patient. The patient reports that she just returned from therapy and the
UAP helped get back to bed. What action would be most effective in preventing
potential complications?
A. Document the findings and continue patient rounds
B. Complete assessment then discuss the findings with the UAP
C. Determine if staff education include proper handling of urinary collection bags
D. Notify MD and report the findings to supervisor ✅b.
The nurse is caring for several patients from culturally diverse backgrounds. Which
actions would be most effective in providing culturally competent nursing care (SATA)
A. Ask patients where they were born
B. Demonstrate an interest in meeting their needs
C. Review the chart to determine ethnicity
D. Print patient education in their native language
E. Limit contact to avoid uncomfortable situations ✅a.
B.
C.
D.
The nurse is caring for a patient in the PACU that had open heart surgery 2 hours ago.
Upon assessment, the patient is moaning softly but appears to be sleeping. HR 84 RR
10 BP 130/82 pulse ox 88% , lactated ringers at 125ml/hr. Urinary catheter with
approximately 200ml of clear yellow urine and the dressing is dry and intact. What
action would the nurse take first?
A. Attempt to wake the patient
, B. Call the surgeon
C. Apply 2L o2 via NC
D. Review the MAR to determine medications given ✅a.
The nurse is providing care for a CHF patient, which actions would the nurse take to
facilitate care coordination? (SATA)
A. Document all care provided in the EMAR
B. Review the MAR and create a list of ordered medication
C. Request a social service referral to match needs with resources available
D. Discuss dietary preferences and practices with patient's family
E. Encourage patient to discuss advance directives with hospital chaplain ✅a.
C.
D.
Assessment findings for a patient admitted 12 hours ago with a CVA includes right side
weakness, garbled speech, BP 190/110, HR 88, RR20, Temp 98.0. The nurse would
call the MD to question which orders.... (SATA)
A. Up ad lib
B. Regular diet
C. VS and neuro checks hourly
D. 0.9% NS at 75ml/hr
E. Compression stockings ✅a.
B.
D.
A patient with abdominal pain 3/10 presents to the outpatient clinic. Lab results show a
hemoglobin of 10.4. The fecal occult test is positive. What topics will the nurse include
in the patient discharge teaching plan? (SATA)
A. Follow high fiber diet
B. Take vitamin C supplements daily
C. Avoid OTC NSAIDS
D. Eliminate alcohol and smoking
E. Adhere to prescribed medications ✅a.
C.
D.
E.
A post op patient blows into the incentive spirometer several times. The patient smiles
and states "see what a good job I'm doing, i'm doing it just like the nurse taught me
yesterday". What action will the nurse take?
A. Explain the proper use and benefits of the spirometer
B. Apply oxygen via nc
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