Adult Health 2 Final Exam.pdf

lOMoARcPSD|38226643 Final Exam for Adult Health II Adult Health II (Oak Point University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by LilNesLyz SS ([email protected]) ...

lOMoARcPSD|38226643 Final Exam for Adult Health II Adult Health II (Oak Point University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 Adult Health II Final 1 The nurse should assess the patient with left-side heart failure for which findings? (SATA) Paroxysmal nocturnal dyspnea Right upper quadrant pain Crackles in the lungs Regular vein distention Fatigue Orthopnea 2 A patient is being screened for diabetes and has two recent fasting blood glucose results of 132mg/dL (7.33mmol/L) and 146mg/dL (8.10mmol/L) How should these result be interpreted? The fasting blood glucose tests should be repeated two more times These results indicate diabetes mellitus. Follow-up is required These are normal results. No further action is needed The patient should be scheduled for a hemoglobin A1c(HbA1C)test 3 A nurse is assessing a patient for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following patient findings should the nurse intervene first? Stridor Urticaria Vomiting Hypotension Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 4 A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? Blood-tinged dialysate outflow Cloudy dialysate outflow Dialysate leakage during inflow Report of discomfort during dialysate inflow 5 A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure(ICP)? Amnesia Tachycardia Altered level of consciousness Hypotension 6 A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the patient receives breakfast by which of the following times? 0720 0815 0745 0730 8 A patient who has been treated for type 1 diabetes mellitus for five years reports numbness and tingling in the lower extremities. What should the nurse teach this patient? Soak your feet daily Massage your lower extremities daily Keep your feet elevated whenever possible Inspect your feet daily Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 9 The mortality rate for burns is highest in the elderly population. What factors put the very elderly at a high risk? (SATA) Elderly tend to heal more slowly The elderly person has a greater proportion of body surface area per amount of body mass The elderly person has less physiological reserves Elderly patients have thicker skin Elderly patients have comorbidities 10 A patient with heart failure has met with his primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? Oxygen saturation Blood pressure Level of consciousness Assessment for nausea 11 The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching? “ I was monitoring my blood glucose every 3to 4 hours” “ I had to stop my insulin” “ I called the doctor because of these symptoms” “ I have been increasing my fluid intake” Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 12 Order: Nitroglycerin IV @20 mcg/min Pharmacy supplies the drug in a 25mg/250ml concentration At what rate in ml/hr is the infusion pump set? Enter a number only 12 mL/hr 13 A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? Hypotension Narrowing pulse pressure Decreased level of consciousness Anuria 14 A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient? Determine triage level and examine and stabilize as needed Give the patient information about facilities that specialize in treating people without health insurance Ask the patient to sign in and provide method of payment for services Transfer the patient to a hospital that specializes in traumatic brain injuries 15 The patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? Sinus tachycardia Atrial fibrillation Sinus bradycardia Atrial flutter Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 16 A nurse in an emergency department is reviewing the medical recoding of a patient who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin 17 A 25 year old female patient has sustained burns to the back of the right arm, front of the entire left leg, and perineum. Using the Rule of Nine, calculate the total body surface area percentage that is burned? 14.5% 22.5% 28% 36% 18 A patient is suspected of sepsis from a postsurgical incision infection. What characteristics of sepsis would the nurse recognize? (SATA) WBCs 9000 Heart rate of 110 beats/minute Blood pressure of 120/80 mmHg Respiratory rate of 20 breaths/minute Temperature of 101F Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 19 A nurse is caring for a patient who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestation. Hyperkalemia Hypervolemia Hypovolemia Hyponatremia 20 Which patient has the greatest risk of developing acute respiratory distress syndrome(ARDS)? A 70 year old adult on long term oxygen therapy A 30 year old adult with an upper respiratory infection A 70 year old adult who aspirated vomit A 50 year old adult seasonal allergies 21 A nurse is preparing to administer a dose of lactulose to a patient who has cirrhosis The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? Glucose Potassium Ammonia Bicarbonate 22 A family member of a patient diagnosed with hemorrhagic stroke asks why the patient did not receive the clot busting medication (tPA). What is the best response? “ Please feel free to aks the neurologist” “ He did not arrive within the time frame for that therapy” “ Use of the drug could cause more bleeding” Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 “ Not everyone is eligible for this drug. Has he had surgery lately?” 23 A nurse is caring for a patient who is postoperative for a right-side mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take? Place the head of the patient’s bed flat Take blood pressures on the patient’s non-affected arm Dangle the operative limb for 5min every hour Keep the drain fully expanded at all times 24 The nurse is reviewing the physician’s orders written for a patient admitted to the hospital 1 hour ago with acute pancreatitis. The patient is in severe pain. Which physician order should the nurse question if noted on the client's chart? Morphine 1 mg IV as needed for pain Insert nasogastric tube IV infusion of 0.9NS at 100cc/hr Clear liquid diet 25 The nurse’s assessment of an older adult patient reveals the following date: Lying BP 144/82 mmHg, sitting BP121/69mmHg; standing BP 98/56 mm Hg. nurse should consequently identify what nursing diagnosis in the patient's plan of care? Risk for imbalance fluid balance related to hemodynamic variability Risk for ineffective role performance related to hypotension Risk for ineffective breathing pattern related to hypotension Risk for falls related to orthostatic hypotension Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 26 A patient is to receive (Lopressor) Metoprolol 100mg. which clinical data will prompt you to hold the medication? Abdominal pain Urine output of 40ml/hr BP 118/60 Heart rate of 50 27 A nurse is caring for a patient in a cardiac care unit. The nurse suspects the patient is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? Muffled heart sounds Bradycardia Sudden lethargy Flattened neck veins 28 The nurse performs a physical assessment on a patient with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/dL, temp of 101 F, pulse of 88 bpm, respirations of 22, and blood pressure of 100/72. Which finding would be of most concern to the nurse? Pulse Blood pressure Respiration Temperature 29 Which of the following modifiable risk factors is the single largest preventable cause of lung cancer? Asbestos Occupational exposure Tobacco Pesticides Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 30 What vascular change would increase afterload? Arterial vasoconstriction Arterial vasodilation Venous vasodilation Venous vasoconstriction 31 A nurse is teaching a patient recently diagnosed with type 1 diabetes mellitus about the chronic microvascular complications associated with the disease. Which information should the nurse include? Buy shoes that are a half size larger Exercise will increase insulin resistance Schedule yearly eye examinations Podiatry visits are necessary every five years 32 While a patient is reviewing IV doxorubicin hydrochloride for the treatment of cancer. the nurse observes swelling and pain at the IV site. The nurse should prioritize what action? Stopping the administration of the drug immediately Notifying the patient’s physician Continuing the infusion but decreasing the rate Applying a warm compress to the infusion site 33 A nurse working in an emergency room is caring for a patient who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions after rewarming? Elevate the legs Apply dry heat to the legs Immerse the legs in cool water Massage the legs Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 34 A nurse is stationed in the triage area in the emergency room. Which would be considered part of the primary survey when initially assessing a patient?(SATA) Cleansing a would on lower extremities Applying a splint to a possible ankle fracture Assessing patient’s circulatory status by checking pulse and blood pressure Assessing patient’s breathing Assessing level of consciousness 35 A nurse in a provider’s office is assessing a patient who has rheumatoid arthritis (RA) Which of the following is a later manifestation of this condition? Joint deformity Fatigue Weight loss Low grade fever 36 A nurse is reviewing the PT, aPTT and INR laboratory values for a patient who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? The laboratory values are decreased The laboratory values are within the expected reference range The laboratory values are the same as the previous test values The laboratory values are prolonged Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 37 A nurse suspects an older adult is experiencing heat stroke base on which of the assessment finding? (SATA) Lack of sweating Temperature 105 Degree F Increased thirst Lowered level of consciousness Bradypnea 38 Order: Dobutamine 5 mcg/kg/min IV Pharmacy supplies the drug in a 200mg/100ml concentration Pt weighs 132IB At what in rate ml/hr should the nurse set the infusion pump? Enter a number only 9mL/hr 39 A patient with diabetes mellitus demonstrates acute anxiety when first admitted hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the patient’s anxiety? Convey empathy, trust, and respect toward the patient Make sure that the patient knows all the correct medical terms to understand what is happening. Ignore the signs and symptoms of anxiety so that they will soon disappear. Administer a sedative Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 40 A nurse is caring for a patient who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Metabolic acidosis Blood pressure 115/68mmHg Mottled skin Heart rate 160/min 41 An immunocompromised older adult has developed bacteremia and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk? Initiate enteral nutrition Apply an antibiotic ointment to wounds Perform active range-of-motion exercises Remove invasive devices as soon as they are no longer needed 42 A nurse is teaching a patient who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include? Examine your feet weekly Avoid eating for 2 hour before exercise Do not exercise if ketones are present in your urine Perform vigorous exercise when blood glucose is less than 100mg/dL 43 Which of the following laboratory values for a patient receiving furosemide (Lasix) requires attention? Blood urea nitrogen 20mg/dl Hematocrit 46% Potassium 3.0mEq/l Creatinine 1.1 mg/dL Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 44 A nurse is teaching a female patient who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the client need for further teaching when she identifies which of the following as a factor that can exacerbate SLE? Stress Exercise Infection Sunlight 45 While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The chest tube is obstructed The system is functioning normally The patient has a pneumothorax The system has an air leak 46 A nurse in the emergency department is caring for a patient who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first? Clean and dress the wound Administer a tetanus booster Administer IV fluids Administer pain medication 47 A patient is brough to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? Endotracheal intubation Intravenous infusion of sodium bicarbonate 100 units of NPH insulin Intravenous infusion of normal saline Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 48 A nurse in an emergency department is caring for a patient who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? Clean the wound Apply a tourniquet just below the elbow Elevate the limb and apply ice Apply direct pressure to the wound 49 A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? Deep partial thickenss(2 nd degree) Superficial thickness(1 st degree) Deep full thickness(4th degree) Full thickness(3rd degree) 50 A patient presents to the ED with acute pulmonary edema and knows that the decreasing venous return is important to immediately relieving symptoms.What intervention should the nurse implement? Administer oxygen Position in high Fowler’s with legs dangling Provide oral furosemide Place in modified Trendelenburg Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 51 A nurse is caring for a patient who has valvular heart disease and is at risk for developing left-side heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? Weight gain Distended abdomen Anorexia Breathlessness 52 A nurse is caring for a patient who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). Decrease in the urinary output from 75 mL to 50 mL per hour. Increase in the heart rate from 88 to 120/min. Decrease in the respiratory rate from 20 to 16/min 53 A nurse is providing discharge instructions for a patient who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective? “ I limit my sodium to 6 grams per day” “ I plan to slow down if I am tired the day after exercising” “ I will take my diuretic before sleep and drink fluids during the day” “ I will weigh myself every other day” 54 A patient admitted to the hospital with a history of type 2 diabetes mellitus is schedule for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Metformin (Glucophage) Regular insulin Repaglinide (Prandin) Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 Glipizide (Glucotrol) 55 The nurse is assessing a patient who is known to have right-sided heart failure. What assessment finding is most consistent with this patient’s diagnosis? Decrease specific gravity Decreased brain natriuretic peptide(BNP) Distended neck veins Orthopnea 56 A patient in the ED experienced a chemical burn over 20% of his body (TBSA). The patient weighs 70kg. Using the following formula, calculate the infusion rate in ml/hr for fluid resuscitation for the first 8 hours. Parkland formula : 4ml* wt in kg *TBSA. Enter a number only 56 mL / 2 = 28 mL/hr first 8 hours 57 A patient chronic renal failure has potassium of 6.5mmE/ml with cardiac arrhythmias. The nurse would expect to use _ to reduce the potassium and cardiac arrhythmias Dextrose IV potassium chloride Oral lactulose Kayexalate Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 58 A nurse in an emergency department is planning care for a patient who is having an acute myocardial infarction (MI) and ask risk for coronary cardiogenic shock. The nurse should plan to administer which of the following medications to manage the patient’s pain and anxiety? Morphine Nitroglycerin Oxygen Aspirin 59 The nurse is assisting with the insertion a left central line into the subclavian vein. The nurse notes that the oxygen saturation is dropping and the patient is short of breath and tachypneic. The nurse suspects a pneumothorax has developed. Which assessment would support that hypothesis? Sudden loss of consciousness Muffled heart sounds Paradoxical chest wall movement with respirations Diminished or absent breath sounds on the affected side 60 The ICU nurse is caring for a patient with multiple organ dysfuction syndrome (MODS) due to shock. What nursing action should be a priority at this point? Provide the family with clear information and emotional support Prepare the family for a long recovery process Educate the patient and family about the treatment plan Plan for rehabilitation phase Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 61 The nurse teaches a patient with diabetes mellitus about deafferenting between hypoglycemia and hyperglycemia. The patient demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? (SATA) Diaphoresis Palpitations Hot, dry skin Shakiness Polyuria Fruity breath odor-hyper 62 A patient is admitted to the emergency room with acute onset of facial drooping and slurred speech. The question “ what time was the patient last fully functional”? is an appropriate assessment to determine which of the following? If the patient will regain all function The prognosis of a hemorrhagic stroke The time required to decrease intracranial pressure The course of treatment for an ischemic stroke 63 A nurse in a burn treatment center is caring for a patient who admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? “Dead tissue will be non- surgically removed” “Large incisions will be made in the eschar to improve circulation” “ This procedure involves placing the patient into a shower and removing the dead tissue” “A piece of skin will be removed and grafted over the burned area” Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 64 Order: gentamycin 1mg/kg IV 8 h administered over 30 minutes. The patient weighs 90 kg. Avaible : Pharmacy sends the first dose in a 100ml bag of normal saline. At what rate in ml/hr will the nurse set the infusion pump? Enter a number only 200 ml/hr 65 A patient with heart failure is placed on a low-sodium diet. Which statement by the patient indicates that the nurse’s nutritional teaching plan has been effective? “ I will have a ham and cheese sandwich for lunch” “ I will have a lossed salad with cheese and croutons for lunch” “ I will have a baked potato with broiled chicken for dinner” “ I will have chicken noodle soup with crackers and an apple for lunch” 66 A nurse is presenting a community based program about HIV and AIDS. A patient asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial Fungal infections Kaposi's sarcoma Pneumocystis lung infection Flu-like symptoms 67 A patient has experienced burns to his upper thighs and knees. Prior to the application of new wound dressings. The nurse should perform what nursing actions? Instruct the patient to keep the wound site in a dependent position. Administer PRN analgesia as ordered. Assist with passive range of motion exercises to set the new dressing. Assess the patients peripheral pulses distal to the dressing. Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 68 When caring for the patient in septic shock, the nurse recognizes fluid replacement is inadequate when which of the following is noted? HR 100 Temp 101.5 MAP 55mmHg BP 95/70mmHg 69 A 50-year-old male is admitted to the emergency department from a house fire. He was found by the firefighter in bedroom with its door closed. He is somnolent, with burns on his face and neck only. It is though that he fell asleep smoking in bed. The nurse recognizes that the highest priority in his care is which of the following? Fluid resuscitation Pain management Manage the airway Reducing risk of infection 70 The nurse is accepting a patient from the ED who has been diagnosed with an acute exacerbation of chronic heart failure. Which nursing diagnosis is a priority at this time? Ineffective health management Anxiety Excess fluid volume Activity intolerance Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 71 A nurse in a clinic is caring for a patient who has a prescription for digoxin. Which of the following statements indicates the patient is experiencing digoxin toxicity? (SATA) Nausea Weight gain Confusion Constipation Blurred and yellow vision 72 The nurse is caring for an older adult patient with a permanent suprapubic catheter who was admitted from a nursing home for increased confusion earlier today. Which of the following should the nurse consider risk for sepsis in this patient (SATA) Chronic conditions Age Exposure to daughter who is receiving chemotherapy An intravenous catheter inserted in the field Presence of a permanent urinary catheter 73 A patient diagnosed with diabetic ketoacidosis (DKA)had a serum glucose level of 485mg/dl(26.92 mmol/L). After treatment with IV insulin, the serum glucose level dropped to 185mg/dl (10.27mmol/L). The patient developed an irregular heart rate. Which assessment finding most likely caused this irregularity? Decreased serum potassium level Elevated serum sodium level Elevated serum glucose level Decreased serum chloride level Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 74 A patient presents to the ED reporting increasing shortness of breath. The nurse assessing the patient notes a history of left-sided Heart Failure. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Pneumonia Progression to Right-sided heart failure Acute pulmonary edema Cardiogenic shock 75 Order: Enalaprilat 1.25mg IVP *1 dose Available : Enalaprilat 2.5mg/2ml How many mls will the nurse draw up? Enter a number only 1 mL The current phase of a patient’s treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? -Acute -Emergent -Rehabilitative -Immediate resuscitative A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? -“Maintain stable blood glucose levels” -Wear compression stocking daily” “Have eye examination once per day” “Examine your feet carefully day” To assess the potency of a newly places arteriovenous graft for dialysis the nurse should do which of the following? -Listen with a stethoscope over the graft for the presence of a bruit -Irrigate the graft daily with low-dose hearing -Monitor for any increase blood pressure in the affected arm Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 -Frequently monitor the pulses and neurovascular status distal in the graft A nurse is teaching a patient who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? -Wear barrier protection during vaginal intercourse - Practice effective hand hygiene -Avoid eating fast food restaurants and red lobsters -wear a mask when out in public A nurse is reviewing laboratory findings for four patients. Which of the following lab values indicated manifestation of acute kidney injury? -Hemoglobin 16g/dL -Serum creatinine 6 mg/dL -BUN 15 mg/dl -Serum potassium 4.5 mEq/L A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? a. "I am gaining weight." b. "I am constipated." *c. "My vision seems yellow." d. "My tongue is red and beefy." A nurse is making a home visit and finds an older adult client who requires immediate treatment for exposure to carbon monoxide. What priority action would the nurse take prior to the arrival of the paramedics? A. loosen all tight-fitting clothing *b. Expose the client to fresh air C. Monitor for breathing difficulties d. Provide warm clothing or a blanket A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? a. Apply a tourniquet just below the elbow. *b. Apply direct pressure over the wound. c. Clean the wound. d. Elevate the limb and apply ice.. A nurse is stationed in the triage area in the emergency room. Which would be considered part of the primary survey when initially assessing a patient? Select all that apply. a. Cleansing a wound on lower extremity *b. Assessing patient's breathing Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 c. Applying a splint to a possible ankle fracture *d. Assessing level of consciousness *e. Assessing patient's circulatory status by checking pulse and blood pressure Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS)? a. 70-year-old adult on long term oxygen therapy *b. 70-year-old adult who is septic c. 30-year-old adult with an upper respiratory infection d. 50-year-old adult seasonal allergies A family member of a patient diagnosed with hemorrhagic stroke asks why the patient did not receive the clot busting medication (tPA). What is the best response? a. "He did not arrive within the time frame for that therapy." b. "Not everyone is eligible for this drug. Has he had surgery lately?" *c. "Use of the drug could cause more bleeding." d. "Please feel free to ask the neurologist." A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? *a. Liver b. Colon c. Reproductive tract d. White blood cells (WBCs) A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition? *a. Lymphedema b. Trousseau's sign c. IV infusion infiltration d. Muscle atrophy While assessing the client, the nurse observes constant tiddling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude? *a. The system is functioning normally. b. The client has a pneumothorax. c. The system has an air leak. d. The chest tube is obstructed. A nurse is assisting a group of patients in an outpatient clinic. For which of the following patients should the nurse anticipate scheduling a colonoscopy? -A 32-year-old who has a sister who died of colon cancer You are caring for a client with a chest tube. When assessing the chest drainage system, you find that the bubbling in the Downloaded by LilNesLyz SS ([email protected])  lOMoARcPSD|38226643 water-seal chamber for the chest tubes is excessive? What should you check for? Question 8 options: See if the wall suction unit has malfunctioned. See if a kink has developed in the tubing. See if there are leaks in the system. See if the chest tube is clogged. Constant bubbling in the water seal of a chest drainage system indicates which problem? a. Air leak b. Tidaling c. Tension pneumothorax d. Increased drainage 7. The nurse is caring for a client following a wedge resection. While the nurse is assessing the client’s chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? a. Air leak b. Tidaling c. Tension pneumothorax d. Increased drainage A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a. Higher than normal endotracheal cuff pressure b. A cut or slice in the tubing from the ventilator c. A kink in the ventilator tubing d. Malfunction of the alarm button Downloaded by LilNesLyz SS ([email protected])