Tiêu đề KEY - R12 NP3.docx ✅

RECALLS 12 NURSING PRACTICE 3 (Part 2) Situation: Cardiovascular diseases are a prevalent health issue in the Philippines, affecting a significant portion of the population. This widespread problem is influenced by factors such as lifestyle, diet, and genetics, making it a major public health concern. 51. Which of the following clinical manifestations would Nurse Colet expect to identify when assessing a patient who has atrial fibrillation? A. Pounding headache B. Visual disturbances C. Irregular radial pulse D. Elevated bird pressure Answer: C Ratio: In patients with atrial fibrillation, physical examination may reveal an irregular pulse, irregular jugular venous pulsations, and irregular S1 heart sounds. Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Twelfth Ed., pg. 731 52. Nurse Colet would expect a patient to describe the symptoms of arterial insufficiency in the lower extremities in which of the following ways? A. "My leg feels weak when I get up to walk." B. "My legs hurt when I walk, but they feel better when I sit down." C. "My feet and ankles become swollen after walking." D. "My feet burn If I walk on a hard surface." Answer: B Ratio: One of the clinical manifestations of arterial insufficiency of lower extremities/peripheral vascular disease is intermittent claudication. Claudication is muscle pain in the affected extremity which happens when you’re active and stops when you rest. Source: https://my.clevelandclinic.org/health/diseases/21972-claudication Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Twelfth Ed., pg. 867 53. Which nursing intervention would be most suitable for managing a patient with peripheral venous insufficiency? A. Elevating the legs B. Increasing the fluid Intake C. Liming the activity level D. Massaging the extremities Answer: A Ratio: Venous insufficiency happens when blood does not flow back up to the heart/blood flows backwards because of damaged valves in your leg veins. This causes blood pooling in the legs resulting in darkened (reddish-brown) skin color on the lower extremities. Elevate your legs higher than the level of your heart to reduce swelling & pressure on your legs and increase blood flow/return. 54. For a client admitted with thrombophlebitis who has been prescribed heparin, what type of administration method should be used? A. Buretrol B. Infusion controller C. Intravenous filter D. Three way stop cock. Answer: B Ratio: To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock. Infusion pump is needed in order to maintain therapeutic effectiveness. Source: Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14th Edition 55. The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin affects the heart by: A. Slowing contractions of the heart B. Dilating coronary blood vessels C. Increasing the ventricular fill time
D. Strengthening contractions of the heart Answer: B Ratio: Nitroglycerin dilates coronary arteries, improves collateral blood flow to ischemic areas within myocardium. IV form of this drug produces peripheral vasodilation. Therapeutic Effect: Decreases myocardial oxygen demand. Reduces left ventricular preload, afterload. Source: Saunders Nursing Drug Handbook 2019, pg. 1868 Situation: Disturbances in the gastrointestinal tract, such as nausea or cramps, can disrupt digestion and cause discomfort. These issues often require attention to diet and sometimes medical treatment to restore normal function. 56. Razell, who had a total gastrectomy, is given instructions on measure to prevent the developing of dumping syndrome. Which of the following statements, if made by the patient, would indicate a correct understanding of the instructions? A. "I will have a bedtime snack." B. "I will rest one hour before each meal." C. "I will avoid concentrated sugar." D. “I will include high-carbohydrate foods in my diet” Answer: C Ratio: Dumping syndrome is a condition in which food, especially food high in carbohydrates, moves from your stomach into your small bowel too quickly after you eat (Rapid gastric emptying). Concentrated sugars/simple sugars like table sugar (sucrose) & fruits (fructose) is avoided. 57. Which of the following laboratory values should Nurse Razell expect to be elevated in a patient who has pancreatitis? A. Red blood cell count B. Blood urea nitrogen C. Glycosylated hemoglobin D. Serum amylase Answer: D Ratio: Pancreatitis is inflammation of the pancreas. Presence of digestive enzymes (serum amylase, serum lipase) in the blood indicates inflammation of the pancreatic tissue causing its leakage. 58. Which of the following statements, if made by Jam who has had a cholecystectomy, would indicate a correct understanding of dietary instructions? A. "I should limit my intake of citrus products.” B. "I must avoid carbonated beverages.” C. "I will Increase high-fiber foods in my diet" D. "I can eat whatever I can tolerate” Answer: D Ratio: There are usually no special dietary instructions in patients who had cholecystectomy other than to maintain a nutritious diet and avoid excessive fats. 59. The nurse should expect to prepare a patient who has bleeding esophageal varices for which of these procedures initially? A. Nasogastric tube feeding B. Normal saline lavage C. Electro cauterization D. X-ray Answer: D Ratio: To stop the bleeding and prevent hemorrhagic shock, the first procedure to be done in patients with bleeding esophageal varices is Balloon Tamponade. The placement of the balloon is confirmed via x-ray 60. Nurse Tres is caring for a patient with acute Hepatitis B. To which of the following measures should she give priority when caring for her patient? A. Using disposable dishes and cutlery for the patient B. Placing the patient in a private room C. Promoting bed rest D. Limiting fluid intake Answer: C. See photo below.