PN 2006 Midterm Review PDF

2006 midterm /50 1\. The nurse would include which of the following in a cardiovascular assessment? a\. All of the above **Vital signs**: Blood pressure, heart rate, respiratory rate, and oxygen saturation. **Inspection**: Skin color (cyanosis, pallor), jugular vein distention (JVD), and swellin...

2006 midterm /50 1\. The nurse would include which of the following in a cardiovascular assessment? a\. All of the above **Vital signs**: Blood pressure, heart rate, respiratory rate, and oxygen saturation. **Inspection**: Skin color (cyanosis, pallor), jugular vein distention (JVD), and swelling in extremities. **Palpation**: Peripheral pulses (strength, symmetry), capillary refill, and skin temperature. **Auscultation**: Heart sounds (rate, rhythm, murmurs) and lung sounds (crackles or wheezing). 2\. If you heard S3 during auscultation of the heart, which of the following is true, select all that apply ? **It may indicate heart failure**: - **It is normal in some individuals**: - **It is heard after S2**: - **It is best heard at the apex**: - **It can indicate a dilated ventricle**: - 3\. A patient has suffered from a severe right sided CVA 2 months ago, the nurse understands that which of the following may be observed with this patient? A patient who suffered a severe right-sided CVA may show left-sided weakness or paralysis (hemiparesis), neglect of the left side, and visual deficits like loss of the left visual field. They might have difficulty with spatial awareness, depth perception, and recognizing objects. Behavioral changes such as impulsivity, poor judgment, or emotional instability are common, along with challenges in focusing and problem-solving. While speech is usually unaffected, they may struggle with nonverbal communication. Nurses should provide supportive care, encourage rehabilitation, and work with the care team to address physical, emotional, and cognitive needs. **4.when you are administering a oxygen to your patient what you have to remember ?** When administering oxygen to a patient, it is essential to assess their needs by monitoring oxygen saturation (SpO₂) and signs of hypoxia, such as confusion or cyanosis. Always follow the prescribed oxygen flow rate and use the appropriate delivery device, such as a nasal cannula or face mask, based on the patient\'s condition. Prevent complications by avoiding excessive oxygen, especially in patients with COPD, and check for skin irritation from the device. Ensure safety by keeping oxygen cylinders secure and avoiding open flames or smoking near oxygen. Continuously monitor the patient's respiratory status and SpO₂, educate them on the therapy and safety measures, and document the flow rate, device used, and patient response. **5. When ur Patient retains CO2 What is it really important they get, select all the apply?** The most important aspects of managing CO₂ retention (hypercapnia) are cautiously administering oxygen to avoid suppressing the respiratory drive, ensuring adequate ventilation (e.g., with CPAP, BiPAP, or mechanical ventilation if needed), and closely monitoring arterial blood gases (ABGs). Effective airway clearance, addressing underlying causes (like infection or obstruction), and providing patient education are also key to preventing complications and managing the condition safely. **6.** The nurse is discussing artieal sclerosis), and the effects it has on the body with an older people, all of the most commonly recognizable effects is on the cardiovascular system. The nurse should include which of the following statements regarding the effects on the GI system to complete the discussion ? When you\'re talking about arterial sclerosis and it\'s a effect on the body with an older client When discussing arteriosclerosis and its effects on the body with an older client, the nurse should include that arteriosclerosis can affect the gastrointestinal (GI) system as well. The thickening and hardening of the arteries may **lead to reduced blood flow to the GI** organs, causing slower digestion, constipation, and potential malabsorption of nutrients. In severe cases, decreased blood flow to the intestines can contribute to ischemic colitis, leading to abdominal pain, bloating, and changes in bowel habits. Additionally, the reduction in blood supply can impact the liver and pancreas, potentially affecting metabolism and digestion. The nurse should emphasize the importance of maintaining a healthy diet, staying hydrated, and engaging in regular physical activity to promote better circulation and digestive health. **7. Which of the following parentheses and practices will have the greatest impact on the containment of bacteria and thus the prevention of cross contamination?** The most effective practices for preventing cross-contamination and containing bacteria include proper hand hygiene, using appropriate personal protective equipment (PPE), cleaning and disinfecting surfaces and equipment, safely handling food and waste, isolating infected patients when needed, and following safe injection practices. **8. If you documenting in your patient progress notes what should it include?** When documenting in a patient\'s progress notes, it is essential to include the date and time of the entry, along with subjective data such as the patient\'s reports of their symptoms, pain levels, and any changes in their condition. Objective data should also be recorded, including vital signs, physical exam findings, lab results, and other observable information. The assessment should summarize your clinical evaluation, highlighting any changes in the patient\'s condition. The plan should outline the next steps in care, including treatments, medications, and further interventions. Additionally, the patient\'s response to interventions should be noted, along with any communication with the healthcare team or family, and instructions provided to the patient. Finally, ensure that your entry is signed with your name and designation, such as LPN, for accountability. This thorough documentation is crucial for ensuring continuity of care and maintaining a legal record of the patient\'s treatment. **9. You notice a sweet smell She was a nurse suspect She was a suspect** A sweet or fruity odor on a patient\'s breath can be a sign of **diabetic ketoacidosis (DKA)**, which is a serious complication of diabetes, often seen in patients with uncontrolled type 1 diabetes. DKA occurs when the body starts breaking down fat for energy instead of glucose, leading to the production of ketones, which can give off a sweet or fruity smell. In this case, the nurse should assess the patient for other signs of DKA, including increased thirst, frequent urination, nausea, vomiting, confusion, and rapid breathing. Immediate medical attention is required to treat this condition. **10. If you are doing an assessment and an older adult what factor considered from heart disease.** When assessing an older adult for heart disease, important factors to consider include a history of hypertension, diabetes, smoking, high cholesterol, family history of heart disease, sedentary lifestyle, and obesity. Age-related changes such as reduced cardiac output, stiffening of blood vessels, and weakened heart muscle should also be taken into account. Additionally, symptoms like shortness of breath, chest pain, fatigue, and edema are common in older adults and could indicate heart disease. **11. You are doing a Cardiovascular assessment what would you pay close attention to?** During a cardiovascular assessment, focus on evaluating vital signs (blood pressure, heart rate), listening for heart sounds (S1, S2, murmurs, or abnormal rhythms), checking for peripheral pulses, observing for signs of fluid retention (edema, jugular venous distention), and assessing for any signs of heart failure, such as shortness of breath or cyanosis. It\'s also important to monitor for risk factors like obesity, smoking, and family history. **12. How and when would you hear high pitch sounds when listening to heart sounds?** High-pitched heart sounds, such as those from a murmur or a pericardial friction rub, are best heard with the **diaphragm** of the stethoscope. These sounds are typically heard during systole or diastole, depending on the type of murmur. High-pitched sounds are more noticeable in cases of conditions like aortic stenosis or mitral valve prolapse and are often best heard at specific points (e.g., the aortic area for aortic stenosis). The sound is typically sharp or blowing. 13\. **You\'ve done , completed a mission assessment for a client Of the following nursing diagnosis which one takes the highest priority.** The highest priority nursing diagnosis after a comprehensive assessment would depend on the patient\'s presenting symptoms. However, in cases of cardiovascular concerns, diagnoses like \"Decreased Cardiac Output,\" \"Ineffective Tissue Perfusion,\" or \"Acute Pain\" could take priority if the patient shows signs of compromised heart function, such as chest pain, dyspnea, or abnormal vital signs. Always prioritize life-threatening conditions and address immediate concerns that could impact the patient\'s stability. **14. Cardiopulmonary Function Related to Older Adults - Which Statement is Correct:\ **As people age, cardiopulmonary function tends to decline. The heart becomes less efficient, and lung tissue loses elasticity, leading to a reduced ability to oxygenate the blood. Older adults are more prone to conditions like heart failure, decreased cardiac output, and respiratory issues. Blood vessels may also become stiffer, increasing the risk of hypertension and atherosclerosis. **15. Assessment of a Client with Right-Sided Heart Failure - What to Expect:\ **In a client with right-sided heart failure, you would expect to find symptoms like peripheral edema (swelling in the legs, ankles, and feet), jugular venous distention (JVD), abdominal distension or ascites, weight gain, and liver enlargement. Patients may also complain of fatigue and shortness of breath, especially when lying down. **16. Alzheimer\'s Disease and Fall Assessment - Greatest Indicator of Fall Risk:\ **In a client with Alzheimer\'s disease, the greatest indicator of fall risk would be **cognitive impairment** and **mobility problems**. These include confusion, difficulty with coordination, balance issues, poor judgment, and inability to recognize environmental hazards. Additionally, medications like sedatives or antipsychotics can increase the risk of falls. **17. How to Limit the Transmission of Pathogens:\ **To limit the transmission of pathogens, nurses should practice good hand hygiene, wear appropriate personal protective equipment (PPE), ensure proper cleaning and disinfection of surfaces and equipment, and educate patients on infection control practices. Isolating patients with contagious diseases, ensuring safe handling of waste, and using sterile techniques when needed also play an important role in limiting pathogen transmission. **18. Assessing Symmetry of the Upper Body - What Position to Use:\ **When assessing symmetry of the upper body, the patient should be in a **sitting position** with their arms at their sides, and the nurse should observe for any differences in muscle size, skin color, or any visible abnormalities. The patient may also be asked to raise their arms to further evaluate symmetry in muscle development and movement. **19. What Does a Respiratory Assessment Include:\ **A respiratory assessment includes evaluating the patient\'s respiratory rate, depth, and rhythm, listening to lung sounds for any abnormalities such as wheezing, crackles, or stridor, assessing oxygen saturation (SpO₂) levels, and checking for signs of respiratory distress (e.g., use of accessory muscles, cyanosis). A thorough history should also be taken to identify risk factors or symptoms such as shortness of breath, cough, or chest pain. **20. What Would a Nurse Expect to See in Orders for a Patient with COPD:\ **For a patient with COPD, the nurse would expect to see orders for **oxygen therapy** to maintain oxygen saturation levels, **bronchodilators** (e.g., albuterol) to relieve airway obstruction, **steroids** (e.g., prednisone) to reduce inflammation, and possibly **antibiotics** if there's evidence of a respiratory infection. Pulmonary rehabilitation or referral to a specialist may also be included in the treatment plan. **21. Teaching a Patient with COPD - Select All That Apply:** - - - - - - **22. Signs and Symptoms of Hypoxia - Select All That Apply:** - - - - - - - **23. Normal Vesicular Breath Sound - What It Is:\ **Normal vesicular breath sounds are soft, low-pitched sounds heard over most of the lungs. They are created during inhalation when air moves through smaller airways (bronchioles and alveoli) and are often described as gentle rustling or breeze-like sounds. These sounds are normal and indicate healthy lung tissue. **24. Best Location to Auscultate for PMI (Point of Maximum Impulse):\ **The best place to auscultate for the PMI is at the **fifth intercostal space, midclavicular line** on the left side of the chest, typically near the apex of the heart. **25. S1 Indicates What:\ **S1 represents the **closure of the mitral and tricuspid valves** (the atrioventricular valves) at the beginning of systole. It is typically heard as a \"lub\" sound and marks the start of the contraction phase of the heart. **26. S2 Indicates What:\ **S2 represents the **closure of the aortic and pulmonic valves** at the end of systole. It is heard as the \"dub\" sound and marks the beginning of diastole, when the heart relaxes and fills with blood. **27. Right-Sided CVA - What Would You Observe - Select All That Apply:** - - - - - - **28. Changing a Patient\'s Colostomy - What to Expect to Find:\ **When changing a patient\'s colostomy, you would expect to find: - - - - Rest are true and false - 20 Midterm Key 1\. The nurse would include which of the following in a cardiovascular assessment? a\. All of the above - 2\. A patient has suffered from a severe right sided CVA 2 months ago, the nurse understands that which of the following may be observed with this patient? a\. 1 + 3 (atrophy of muscles in left arm and leg and hemiparesis to left side of the body) 3\. The nurse is discussing (something sclerosis), and the effects it has on the body (didn't hear this part either), all of the most commonly recognizable effects is on the cardiovascular system. The nurse should include which of the following statements regarding the effects on the GI system to complete the discussion? a\. Problems it creates with blood flow also affects blood flow to the bowels and so it affects elimination.4. **Why is it usually advised for a cardiovascular condition who has CV to not strain, what** **happens to BM** a\. Can cause a heart attack 5\. The nurse is providing ancillary personal with instructions regarding the proper methods to implement when caring for a client with C. Diff, which of the following practices will have the greatest impact on containment on the bacteria and prevention on cross contamination a\. Practicing proper hand hygiene by all staff 6\. The nurse uses all (something) during a client's assessment, if a sweet fruity smell is noticed in the oral cavity, which of the following should the nurse suspect? a\. Diabetes acidosis 7\. Which of the following assessment findings in the older adult would be considered risk factor for heart disease a\. All of the above 8\. When performing a cardiovascular assessment, the nurse would pay close attention to which of the following? a\. All of the above 9\. To listen to heart sounds, the best way to hear to high-pitched sounds is with: a\. Diaphragm 10\. Which of the following statement is incorrect regarding the older adult client in cardio pulmonary function a\. Older adults are easily bothered by dyspnea and complain to the nurse T/F 11\. An individual with COPD has dyspnea, poor gas exchange, and increased risk for infection. a\. **True** 12\. Tactile fremitus is the vibration felt throughout the lungs during speech a\. **True** 13\. A younker suction is used to suction oral secretions a\. **True** 14\. A non-rebreather mask is appropriate for low flow oxygen of 3L/min or less a\. **False** 15\. An irregular heartbeat and dizziness may be considered normal assessment findings within the geriatric populations a\. **False** 16\. Erythema is a term used to describe pale skin as one will see with anemia a\. **False** 17\. The point of maximum impulse refers to the apex of the heart a\. **True** 18\. Crackles caused by pulmonary edema can be cleared through coughing a\. **False** 19\. A colostomy bag should be emptied when its ¼ - ½ gas full or feces a\. **True** 20\. Bowel sounds can be said to be absent if the nurse does not hear them in the first minute of auscultating a\. **False** 21\. When evaluating muscle strength as is done during musculoskeletal assessment, the nurse should observe the person's gait a\. **True** 22\. When performing an abdominal assessment, the nurse should palpate the painful areas last a\. **True** 23\. It may be appropriate to assign the task of taking vitals of the stable patient to a unregulated healthcare provider a\. **True** 24\. A doppler device may be used to assess peripheral pulses in a patient with peripheral vascular disease a\. **True** 25\. When assessing pallor of an individual with a dark skin tone the nurse may observe the gums or conjunctiva of the eye as an alternative a\. **True** 26\. A peak expiratory (something) of maximum air flow of air that (something) when one quick forced expiration is taken a\. **True** 27\. The correct patient positioning of deep breathing and coughing is a low fowlers position a\. **False** 28\. When a patient is experiencing respiratory distress, the first action the nurse should do every time is apply supplemental oxygen a\. **False** 29\. Oxygen saturations between 85-100% would be considered normal a\. **False** 30\. Is it important that the nurse dons' sterile gloves when performing oral and nasal suctioning a\. **False** 1\. An individual with COPD has dyspnea, poor gas exchange, and increased risk for infection. True Explanation: COPD often causes dyspnea, impaired gas exchange, and susceptibility to infections due to weakened lung defenses. 2\. Tactile fremitus is the vibration felt throughout the lungs during speech. True Explanation: Tactile fremitus is the vibration felt on the chest wall when a patient speaks, indicating the transmission of sound through lung tissue. 3\. A yankauer suction is used to suction oral secretions. True Explanation: Yankauer suction devices are specifically designed for oral secretions. 4\. A non-rebreather mask is appropriate for low flow oxygen of 3L/min or less. False Explanation: Non-rebreather masks deliver high concentrations of oxygen and require higher flow rates (usually 10-15 L/min) to prevent CO2 buildup. 5\. An irregular heartbeat and dizziness may be considered normal assessment findings within the geriatric population. False Explanation: While irregular heartbeat and dizziness are more common in older adults, they are not considered "normal" and warrant investigation. 6\. Erythema is a term used to describe pale skin as one will see with anemia. False Explanation: Erythema refers to redness of the skin, while pallor is associated with anemia. 7\. The point of maximum impulse refers to the apex of the heart. True Explanation: The PMI is usually located at the apex of the heart, typically at the 5th intercostal space, midclavicular line. 8\. Crackles caused by pulmonary edema can be cleared through coughing. False Explanation: Crackles in pulmonary edema are due to fluid in the alveoli and cannot be cleared by coughing. 9\. A colostomy bag should be emptied when it is ¼ - ½ full of gas or feces. True Explanation: This prevents excessive weight and leakage. 10\. Bowel sounds can be said to be absent if the nurse does not hear them in the first minute of auscultating. False Explanation: Bowel sounds are only considered absent after auscultating for a full 5 minutes. 11\. When evaluating muscle strength as is done during musculoskeletal assessment, the nurse should observe the person's gait. True Explanation: Observing gait helps evaluate muscle strength, balance, and coordination. 12\. When performing an abdominal assessment, the nurse should palpate the painful areas last. True Explanation: This minimizes discomfort and prevents guarding that could affect the rest of the assessment. 13\. It may be appropriate to assign the task of taking vitals of the stable patient to an unregulated healthcare provider. True Explanation: UCPs can take vitals on stable patients under appropriate delegation and supervision. 14\. A doppler device may be used to assess peripheral pulses in a patient with peripheral vascular disease. True Explanation: Doppler devices are often used to locate weak or absent pulses in such patients. 15\. When assessing pallor of an individual with a dark skin tone, the nurse may observe the gums or conjunctiva of the eye as an alternative. True Explanation: These areas are less affected by skin pigmentation and can show changes in circulation or anemia. 16\. A peak expiratory flow measures maximum airflow during one quick forced expiration. True Explanation: This is the correct description of a peak expiratory flow measurement. 17\. The correct patient positioning for deep breathing and coughing is a low Fowler's position. False Explanation: A high Fowler's or semi-Fowler's position is typically recommended to promote lung expansion. 18\. When a patient is experiencing respiratory distress, the first action the nurse should do every time is apply supplemental oxygen. False Explanation: The first action is to assess the patient and identify the cause of respiratory distress before deciding on interventions like oxygen. 19\. Oxygen saturations between 85-100% would be considered normal. False Explanation: Normal oxygen saturation is 95-100%; values below 90% indicate hypoxemia. 20\. It is important that the nurse dons sterile gloves when performing oral and nasal suctioning. False Explanation: Clean (not sterile) gloves are used for oral and nasal suctioning.