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NUR215 Adult Nursing I Exam 4
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NUR215 Adult Nursing I Exam 4
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Exam IV NUR215 Adult Nursing I,Question 1
pts
A nurse assesses an older adult patient who has multiple chronic diseases. The
patient’s heart rate is 48 beats/min. What action would the nurse take first?
Administer 1 mg of atropine.
Correct!
Assess the patient’s medications.
Initiate external pacing.
Document the finding in the chart.
Pacemaker cells in the conduction system decrease in number as a person ages,
resulting in bradycardia. The nurse would check the medication reconciliation for
medications that might cause such a drop in heart rate, and then would inform the
healthcare provider. Documentation is important, but it is not the priority action. The
heart rate is not low enough for atropine or an external pacemaker to be needed.
Question 2
pts
A nurse assesses an older adult patient who is experiencing a myocardial infarction.
Which clinical manifestation would the nurse expect?
Left lateral chest wall pain
Excruciating pain on inspiration
Correct!
,Disorientation and confusion
Numbness and tingling of the arm
In older adults, disorientation or confusion may be the major manifestation of myocardial
infarction caused by poor cardiac output. Pain manifestations and numbness and
tingling of the arm could also be related to the myocardial infarction. However, the nurse
would be more concerned about the new onset of disorientation or confusion caused by
decreased perfusion.
Question 3
pts
A nurse cares for a patient who is prescribed magnetic resonance imaging (MRI) of the
heart. The patient’s health history includes a previous myocardial infarction and
pacemaker implantation. What action would the nurse take?
Call the physician and request a laboratory draw for cardiac enzymes.
Schedule an electrocardiogram just before the MRI.
Correct!
Notify the healthcare provider before scheduling the MRI.
Instruct the patient to increase fluid intake the day before the MRI.
The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the
healthcare provider and report that the patient has a pacemaker so the provider can
order other diagnostic tests. The patient does not need an electrocardiogram, cardiac
enzymes, or increased fluids.
Question 4
pts
,A nurse assesses a patient who is recovering from a myocardial infarction. The patient’s
blood pressure reading is 140/88 mm Hg. What action would the nurse take first?
Increase the intravenous fluid rate because these readings are low.
Immediately notify the healthcare provider of the elevated blood pressure.
Correct!
Compare the results with previous blood pressure readings.
Document the finding in the patient’s chart as the only action.
Normal blood pressures range from 90 to 140 mm Hg for systolic and from 60 to 90 mm
Hg for diastolic. Although this patient’s readings are within normal limits, the nurse
needs to assess any trends that may indicate a need for medical treatment to prevent
complications. There is no need to increase intravenous fluids or notify the provider.
Question 5
pts
A nurse cares for a patient who has an 80% blockage of the right coronary artery (RCA)
and is scheduled for bypass surgery. Which intervention would the nurse be prepared to
implement while this patient waits for surgery?
Correct!
Initiation of an external pacemaker
Assistance with endotracheal intubation
Administration of IV furosemide (Lasix)
, Placement of central venous access
The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and
atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the
patient totally occludes the RCA, the AV node would not function and the patient would
go into heart block, so emergency pacing should be available for the patient.
Furosemide, intubation, and central venous access will not address the primary
complication of RCA occlusion, which is AV node malfunction.
Question 6
pts
A nurse teaches a patient with diabetes mellitus and a body mass index of 42 who is at
high risk for coronary artery disease. Which statement related to nutrition would the
nurse include in this patient’s teaching?
Correct!
“You should balance weight loss with consuming necessary nutrients.”
“The best way to lose weight is a high-protein, low-carbohydrate diet.”
“If you exercise more frequently, you won’t need to change your diet.”
“A nutritionist will provide you with information about your new diet.”
Patients at risk for cardiovascular diseases should follow the American Heart
Association guidelines to combat obesity and improve cardiac health. The nurse would
encourage the patient to eat vegetables, fruits, unrefined whole-grain products, and fat-
free dairy products while losing weight. High-protein food items are often high in fat and
calories. Although the nutritionist can assist with patient education, the nurse would
include nutrition education and assist the patient to make healthy decisions. Exercising
and eating nutrient-rich foods are both important components in reducing cardiovascular
risk.
Question 7
pts
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