Exam 3: NUR201/ NUR 201 (New 2024/ 2025 Update) Medical Surgical Nursing I Guide | Questions and Verified Answers| 100% Correct| A Grade – Fortis
QUES... [Show More] TION
you have a patient post cardiac catherization with femoral access, what interventions should you include in your plan of care
Answer:
a. avoid heavy lifting (more than 10 pounds) and pushing or pulling heavy objects for the first 5-7 days after the procedure
QUESTION
what step should you take to obtain an accurate BP for a hypertensive patient
Answer:
have the patient sit in a chair with the feet flat on the floor
QUESTION
which finding from a patient newly diagnosed with HTN is most important to address with the patient
Answer:
a. no regular physical exercise
b. no regular aerobic exercise
QUESTION
what action should the nurse take when giving first dose of labetalol to a patient with HTN
Answer:
ask the patient to request assistance when getting out of bed
QUESTION
which diet modification for stage 1 HTN patient shows teaching was effective
Answer:
a. the patient has a glass of low-fat milk with each meal
QUESTION
patient diagnosed with HTN is prescribed captopril, what info is most important to teach the patient
Answer:
change position slowly to help prevent dizziness and falls
QUESTION
propranolol is prescribed to a patient with HTN. The PCP needs to be consulted if the patient reveals a history of which disease process
Answer:
a. asthma
b. bronchospasms
QUESTION
62 yr old patient with no previous history of HTN now has confirmed BP of 198/110. what is appropriate for you to tell the patient
Answer:
diagnosis of a possible cause, treatment, and ongoing monitoring will be needed
QUESTION
hypertensive patient receives first dose of nadolol what information shows need for immediate intervention
Answer:
a. the patient has developed wheezes throughout the lung fields
b. bradycardia, orthostatic hypotension
c. may cause bronchospasms
QUESTION
patient diagnosed with possible white coat syndrome, which action by the nurse addresses this cause of HTN
Answer:
tell the patient how to self monitor and record BP at home
QUESTION
what information is important to share with a newly diagnosed patient with HTN
Answer:
hypertension is usually asymptomatic until target organ damage occurs
QUESTION
patient in ICU with hypertensive emergency what finding is most important to report to healthcare provider
Answer:
the patient cannot move the left arm and leg when asked to do so
QUESTION
a 70 yr old patient takes HCTZ and enalapril. the patient BP remains high, what patient info may indicate a need for change
Answer:
a. patients use ibuprofen dailty to treat osteoarthiritis (HCTZ)
b. hyponatremia (HCTZ)
c. jypokalemia (HCTZ)
d. orthostatic hypotension (HCTZ)
e. angioedema (enalapril)
f. systemic hypotension (enalapril)
g. intractable cough (enalapril)
h. renal insufficiency (enalapril)
QUESTION
what statement made by patient with CAD regarding diet modifications required further teaching
Answer:
"I will miss being able to eat peanut butter sandwiches "
QUESTION
patient with HTN has new order for captopril, what information should you include in patient teaching
Answer:
change position slowly to help prevent dizziness and falls
QUESTION
patient arrived on tele unit after cardiac catheterization, what can you delegate to LPN
Answer:
the LPN has the patient sit in a chair for 2 hours ----
graduated compression stockings
avoid prolonged sitting
QUESTION
64 yr old patient with CAD, which factor should you focus on during patient teaching
Answer:
elevated low-density lipoprotein (LDL) level >130
want less than 130
QUESTION
CAD patient needs to make dietary changes, what interventions would be most appropriate
Answer:
help the patient modify favorite high-fat recipes by using monounsaturated coils
QUESTION
mildly obese 68 yr old patient wants to increase physical activity
Answer:
determine what kind of physical activities the patient usually enjoys
QUESTION
when teaching a patient with PAD, what group of drugs should be included in the plan
Answer:
statins
QUESTION
patient states that he gets cramps soon after he walks that are relieved when he rests, what is the focused nursing assessment
Answer:
palpate for the presence of the dorsalis pedis and posterior tibial pulses
QUESTION
patient has chronic PAD, what should you expect to find on assessment
Answer:
prolonged capillary refill in all the toes
QUESTION
what statement by a patient with chronic PAD indicates further teaching
Answer:
i use a heating pad on my feet at night to increase the circulation and warmth my feet
QUESTION
what statement by a patient taking warfarin for VTE indicated need for further teaching
Answer:
a. I should reduce the amount of green leafy vegetables that i eat
b. I have started taking ginger root to treat my joint stiffness
QUESTION
what patient statement is most consistent with venouse insufficiency
Answer:
I cant get my shoes on at the end of the day
QUESTION
after the shift change report which patient should you see first
Answer:
a 50 yr old patient who is complaining of sudden sharp and sever upper back pai
QUESTION
cardio vasc assessment
Answer:
listen at apex with pt sitting up, leaning forward to the left
QUESTION
pulsation in epigastric area
Answer:
normal in THIN geriatric patients
QUESTION
patient education regarding sclerotherapy
Answer:
elastic compression stockings should be applied before getting out of bed
QUESTION
patient teaching on self care for chronic venous insufficiency
Answer:
elevate legs
QUESTION
patient with HTN taking newly prescribed calcium channel blocker, what should you include in teaching
Answer:
amlodapine
swelling in legs and feet
QUESTION
patient with HTN taking HCTZ, what lab result reflects the need for a change in medication
Answer:
low potassium
QUESTION
in preparing a patient for cardiac catheterization what is most important to assess or verify
Answer:
baseline vitals
allergies
QUESTION
what initial action should you take after cardiac catheterization
Answer:
a. clients must remain supine 6 hrs with the head of the bed flat and the affected extremity straight to prevent bleeding from the catheter insertion site.
b. the charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal
QUESTION
patient newly diagnosed with reynauds; what patient statements would indicate correct understanding
Answer:
a. exercises indoors during winter months
b. "I should not smoke"
c. protect against the cold by wearing layers of clothing
d. avoid temperature extremes
e. stop using tobacco
f. avoid caffeine
QUESTION
s1
Answer:
closure of tricuspid and mitral valves "lubb"
beginning of systole
QUESTION
s2
Answer:
closure of aortic and pulmonic valves "dubb"
beginning of diastole
QUESTION
pulse deficit
Answer:
palpate radial pulse when listening to apical; felt between s1 and s2
QUESTION
s3 and s4
Answer:
use bell of stethoscope
lean forward. 2nd ICS aortic and pulmonic
left side lying bring heart closer to chest wall - mitral assessment
QUESTION
s3
Answer:
ventricular gallop
left heart failure or mitral regurgitation
QUESTION
s4
Answer:
atrial gallop
cas. cardiomyopathy, aortic stenosis
QUESTION
Point of maximal impulse (PMI)
Answer:
Where heartbeat is best palpable on chest wall; 5th intercostal space, midclavicular line
QUESTION
conduction system
Answer:
SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers
QUESTION
HR
Answer:
does not change when getting older
QUESTION
ECG nursing priority
Answer:
do not need an order for pt complaining of chest pains
QUESTION
pulse pressure
Answer:
systolic pressure - diastolic pressure
QUESTION
Mean Arterial Pressure (MAP)
Answer:
systolic + 2(diastolic) / 3
needs to be >60 to perfuse vital organs
pedal ____ cannot be felt if <65
QUESTION
when to expect jugular vein distention
Answer:
patients lying flat - raise HOB >45
patients during Valsalva maneuver
QUESTION
coronary artery disease
Answer:
atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle
most common
QUESTION
age related changes
Answer:
Increased collagen, decreased elastin
Decreased response to stress
Heart valves become thick and stiff
Number of pacemaker cells decrease
Decreased number and function of β-adrenergic receptors
Blood vessels thicken and less elastic
Increase in SBP and decrease or no change in DBP
Incompetent venous valves
Orthostatic hypotension
Postprandial hypotension
QUESTION
catherization pre op
Answer:
npo 6-12 hours
QUESTION
Cath post op
Answer:
do not bend at 90 degrees
will be supine flat can be up to 6 hours
QUESTION
HTN BP management
Answer:
no smoking, exercise, or caffeine 30 min prior to taking
deflate 2-3 mm hg/sec
for dysrhythmias take both arms
QUESTION
Hypertension Clinical Manifestations
Answer:
- Frequently asymptomatic until it becomes severe and target organ disease has occurred
- Fatigue, reduced activity tolerance
- Dizziness
- Palpitations, angina
- Dyspnea
QUESTION
heart valves
Answer:
aortic, pulmonic, tricuspid, mitral
chordae tendineae, papillary muscle
QUESTION
systolic pressure
Answer:
The blood pressure generated by the heart during contraction.
QUESTION
Diastole
Answer:
Relaxation of the heart
QUESTION
what finding on a 12 lead ekg is most concerning to the nurse
Answer:
ST elevation
QUESTION
after palpating the point of maximum impulse what is the best focused follow up action for the nurse to take
Answer:
a. assess for symptoms of left ventricular hypertrophy
b. determine the timing of the murmur
c. mitral valve left side fifth intercostal space midclavicular line
QUESTION
how do you auscultate for s3 or s4 gallops in the mitral area
Answer:
bell of the stethoscope with the patient in the left lateral position
QUESTION
during an assessment you observe pulsation of the abdominal aorta in the epigastric area, what is your next action
Answer:
document the finding in the patient chart
QUESTION
patient has heart failure with jvd while lying flat, what follow up action should you take
Answer:
pt lying flat - raise HOB >45
patients during valsalva manuver
QUESTION
during assessment you note a murmur, to get more info, what is your next action
Answer:
assess for a change in the murmur during a change in the client's position
determine the location on the client's chest where the murmur is best heard
note how easily the murmur is heard by gradually lifting the stethoscope
QUESTION
you hear a murmur between s1 and s2 between left 5th intercostal space and midclavicular line, how is that documented
Answer:
systolic murmur heard at mitral area [Show Less]