Exam (elaborations)
HR MISC AHFinal Adult Health III Final.
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HR MISC AHFinal Adult Health III Final/ HR MISC AHFinal Adult Health III Final.
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1Adult Health III Final
1. A patient presents with liver injury due to history of Tylenol misuse. On arrival the patient is
unconscious. After giving him 3 liters of IV fluids, the nurse did an assessment. The findings were
bilateral 2+ pedal edema, BP 160/90, HR 115.
What would be the priority assessment the nurse should do next? Assess lung
sounds
2. After intervention and stopping fluids and giving a small dose of Lasix, the patient became a
little responsive. ABG labs results came back, the results are as follows: pH 7.28, PaCO2 38, PAO2 89,
HCO3 17.
Is there a sign of acid base imbalance in these values? Yes
What type of acid base imbalance would this be? Metabolic Acidosis
3. A COPD patient is admitted with hypoxemia due to V/Q mismatch. The nurse is anticipating the
delivery system that will be used to provide oxygen. What type of oxygen flow would you provide for
this patient?
low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen.
4. A trauma patient who has acute heart failure has not gotten out of bed and has not being
using his incentive spirometry became very restless. Vital signs reveals signs of decrease cardiac
output (low BP, bradycardic with thready pulse). A chest X-ray reveals pneumonia. What would be
the priority intervention for this patient?
intubate
5. What medication prescribed for this patient would you want to
clarify? Azithromycin (due to pt’s heart condition)
6. The patient is found to have fluids in the lungs due to bronchiectasis and requires postural
drainage 3X daily.
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What would be some essential teaching essential teaching necessary for this
patient about postural drainage? Three hours after meals to allow food to digest- to
prevent aspiration, use of pillows to position client, give bronchodilator (albuterol)
before procedure, percuss over a towel (or a pillow case) to ensure it does not feel
uncomfortable
7. A patient presents to the ED with complaints of the heart feeling fluttering. The MD orders for the
patient to be placed on telemetry.
Looking at the strip, how would you calculate the HR?
Count up the QRS complex and multiply by 10 (for 6 second strips)
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8. the patient is diagnosed with atrial flutter. What are the clinical manifestations the patient
would present with?
It is associated with CAD, hypertension, mitral valve disorders, pulmonary embolism,
chronic lung disease, cor pulmonale, cardiomyopathy, hyperthyroidism, and the use of drugs
such as digoxin, quinidine, and epinephrine (page 765)
9. Where on the body should the electrodes be placed?
Upper leads (white & black) on clavicle line, lower leads (green & red) right below rib
cage, and brown lead on the right of sternum
10. A patient comes in complaining of epigastric pain, lower back pain. On examination the nurse
finds a feeling of an abdominal pulsatile mass. Assessing the BP she hears a systolic bruit. What
would be the expected diagnosis?
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Abdominal Aortic Aneurysm
11. After having an abdominal xray the patient is diagnosed with AAA. The nurse turns the patient to
assess the skin and finds ecchymosis on the back. What would be the priority action? Obtain informed
consent for emergency surgery
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