1. A patient presents with liver injury due to history of Tylenol abuse. On arrival the patient is unconscious. After giving him 3 liters of IV fluids the
... [Show More] nurse does an assessment. The findings were bilateral 2+ pedal edema, BP 160/90, HR 115. What would be the priority assessment the nurse should do next?
a. Assess the lung sounds.
2. After interventions, stopping fluids, and giving a small dose of Lasix the patient became a little responsive. ABG lab results come back and are as follows: pH 7.28 PaCo2 38 PaO2 89 HCO3 17. Is there a sign of acid base imbalance?
a. Yes, metabolic acidosis.
3. A COPD patient is admitted with hypoxemia due to VQ mismatch. The nurse is anticipating the delivery system that is used to provide oxygen. What type of oxygen flow would you provide for this client?
a. Low levels of oxygen either via nasal cannula or using a face mask at 24%-32% oxygen.
4. A trauma patient who has acute heart failure has not gotten out of bed and has not been using the incentive spirometer has become very restless. Vital signs reveal signs of decreased cardiac output (low BP, bradycardic, and a thready pulse). A chest x ray reveals pneumonia. What would be the priority intervention for this patient?
a. Prepare them for intubation.
5. What medication prescribed for the patient above would you want to clarify? a. Azithromycin due to the client’s heart condition.
6. The patient is found to have fluids in the lungs due to bronchiectasis (damage to the airways making it difficult to clear mucus) and requires postural drainage 3x daily. What would be some essential teaching for this patient regarding postural drainage?
a. It needs to occur prior to or 3 hours after meals, use of pillows to position client, give bronchodilator (albuterol) before the procedure, percuss over a towel to ensure there is no discomfort.
7. A patient presents to the ED with complaints of feeling fluttering of the heart. The MD orders for this patient to be placed on telemetry. Looking at the strip, how would you calculate the HR?
a. Count the QRS complexes and multiply by 10 (for a 6 sec strip).
8. The patient is diagnosed with Atrial Flutter. What are the clinical manifestations the patient would present with?
a. CAD, HTN, mitral valve disorders, pulmonary embolism, chronic lung disease, cor pulmonale, cardiomyopathy, hyperthyroidism, and the use of drugs such as digoxin, quinidine, and epinephrine (pg 765).
9. Where on the body should the electrodes be placed for a 5 lead EKG?
a. White on upper right near mid clavicular line, black on upper left near mid clavicular line, green on lower right between 6th and 7th intercostal space, and red lower left between 6th and 7th intercostal space, with the brown lead just right of the sternum at 4th intercostal space.
10. A patient comes in complaining of epigastric pain and lower back pain. On examination the nurse palpates an abdominal pulsatile mass. Assessing the BP she hears a systolic bruit. What would be the expected diagnosis?
a. Triple A or abdominal aortic aneurysm. [Show Less]