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.
Situation: A chest tube thoracostomy is a medical procedure where a tube is inserted into the chest cavity to remove air, fluid, or pus and allow the lungs to fully expand. It’s often used to treat conditions like pneumothorax (air in the chest), pleural effusion (fluid in the chest), or empyema (infected fluid in the chest). 61. Maku returned from thoracic surgery 3 hours ago with two chest tubes placed at 20cm suction. Which findings would be considered abnormal? A. Bubbling in the suction control chamber B. 350 cc of sanguineous drainage in the drainage chamber over the last 3 hours C. No fluctuation in the water seal chamber D. Small amount of sanguineous drainage on the chest tube dressing Answer: C Ratio: No fluctuations in the water seal chamber may mean that there is obstruction on the chest tube system (bad indication) or lungs have re-expanded (good indication). 62. Nurse Gen is caring for Justine, a client who has just undergone a left pneumonectomy, knows that she should position Justine on: A. The back with the head of the bed flat B. The left side with the head of the bed flat C. The left side with the head of the bed elevated D. The right side with the head of the bed elevated Answer: B Ratio: Left side-lying in supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump. This allows the fluid left in the operated space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. 63. While Nurse Gen is assessing the client who has a chest tube, she notes that the tubing is kinked between the bedrails. Nurse Gen knows that this places the client at increased risk for: A. Tension pneumothorax B. Air leak C. Hemorrhage D. Cardiac tamponade Answer: A Ratio: Kinking, looping, or pressure on the drainage tubing can produce back-pressure, which may force fluid back into the pleural space or impede the removal of trapped air (w/c can cause tension pneumothorax) 64. Dianhel is rushed to the emergency department due to a pneumothorax secondary to a gunshot wound. She complains of shortness of breath and exhibits tracheal and mediastinal shifts to the left. For which procedure should her nurse prepare Dianhel? A. Intubation with an endotracheal tube B. Insertion of a closed chest drainage tube C. Paracentesis D. MRI of the chest Answer: B Ratio: Patient should be prepared for chest tube insertion to remove the accumulated air and blood/fluids and to relieve the pressure on the trachea and mediastinum. 65. Dr. Rocky is preparing to remove the chest tube from the client's left chest. To prepare for the procedure, the nurse should advise the client to: A. Breathe normally B. Hold his breath and bear down C. Take a deep breath D. Sneeze on command Answer: B Ratio: When assisting in the chest tube’s removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. This is done to prevent air from entering the pleural cavity as the tube is withdrawn. Situation: Nurse Neil is reviewing his knowledge regarding Pancreatitis for his upcoming board examination this November.