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


66. Nurse Neil knew that the initial diagnosis of pancreatitis is confirmed if the client's blood shows a significant in elevation which of the following serum values? A. Amylase B. Calcium C. Potassium D. Trypsin Answer: A Ratio: Pancreatitis is inflammation of the pancreas. Elevated presence of digestive enzymes (serum amylase, serum lipase) in the blood indicates inflammation of the pancreatic tissue causing its leakage. 67. In a client with acute pancreatitis, Nurse Neil should anticipate observing the following signs and symptoms: A. Diarrhea B. Jaundice C. Hypertension D. Ascites Answer: D 68. Nurse Neil reviews the client's latest laboratory results. What findings would indicate a diagnosis of acute pancreatitis? A. Hyperglycemia B. Leukopenia C. Thrombocytopenia D. Hyperkalemia Answer: A Ratio: Serum glucose is increased because of impaired excretion of insulin d/t pancreatic injury 69. Nurse Neil reviews initial plan for a client with pancreatitis would most likely focus on which of the following as a priority? A. Resting the gastrointestinal tract B. Ensuring adequate nutrition C. Maintaining fluid and electrolyte balance D. Preventing the development of an infection Answer: A Ratio: Question is asking about the initial plan. Initial plan is to put the patient in NPO to rest the GIT, prevent stimulation of pancreas and prevent further painful distention in the patient. 70. Nurse Neil knows that if a client is diagnosed with acute pancreatitis, he should carefully monitor the client for which of the following complications? A. Congestive heart failure B. Duodenal Ulcer C. Cirrhosis D. Pneumonia Answer: D Ratio: The patient with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis. Situation: Nurse Anne, an infectious control nurse, is caring for a client with Pulmonary Tuberculosis. 71. Which client has special risk factors that warrant testing for tuberculosis? A. 45-year-old Caucasian man who has been homeless for 2 years B. 15-year-old Caucasian woman with asthma C. 72-year-old woman who is a recent immigrant from Russia D. 50-year-old Iowa farmer Answer: A Ratio: One of the risk factors for TB is any person without adequate health care (the homeless, impoverished; minorities, particularly children under age 15 and young adults between ages 15 and 44) Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Twelfth Ed., pg.567