Foundations Final From Evolve-Chap. 17, 18, 19, 20, 23, 26,
29, 30, 31, 41, 45, 48, & 50 Questions With Complete
Solutions
A 52-year-old woman is admitted with dyspnea and discomfort
in her left chest with deep breaths. She has smoked for 35 years
and recently lost over 10 pounds. Her vital signs on admission
are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8°C
(98.2°F), and oxygen saturation 94%. She is receiving oxygen at
2 L via a nasal cannula. Which vital sign reflects a positive
outcome of the oxygen therapy?
A. Temperature: 37°C (98.6°F)
B. Radial pulse: 112
C. Respiratory rate: 24
D. Oxygen saturation: 96%
E. Blood pressure: 134/78 Correct Answer D. Oxygen
saturation: 96%
Oxygen therapy increases oxygen saturation. Temperature is not
affected by the oxygen. There is no change in heart rate.
Administering oxygen should decrease the respiratory rate. The
decline in blood pressure is unlikely to be caused by oxygen.
A 55-year-old widowed patient was in a motor vehicle accident
and is admitted to a surgical unit after repair of a fractured left
arm and left leg. She also has a laceration on her forehead. An
intravenous (IV) line is infusing in the right antecubital fossa,
and pneumatic compression stockings are on the right lower leg.
She is receiving oxygen via a simple face mask. What sites do
you instruct the nursing assistant to use for obtaining the
patient's blood pressure and temperature?
,A. Right antecubital and tympanic membrane
B. Right popliteal and right axillae
C. Left antecubital and oral
D. Left popliteal and temporal artery Correct Answer B. Right
popliteal and right axillae
The only extremity that does not have a compromised artery to
auscultate is the right lower leg after the sequential device is
removed. The tympanic membrane and temporal artery are
affected by facial surgery and oxygen mask.
A 56-year-old patient with diabetes admitted for community
acquired pneumonia has a temperature of 38.2°C (100.8°F) via
the temporal artery. Which additional assessment data are
needed in planning interventions for the patient's infection?
(Select all that apply.)
A. Heart rate
B. Presence of diaphoresis
C. Smoking history
D. Respiratory rate
E. Recent bowel movement
F. Blood pressure in right arm
G. Patient's normal temperature
H. Blood pressure in distal extremity Correct Answer A. Heart
rate
B. Presence of diaphoresis
D. Respiratory rate
G. Patient's normal temperature
You need to determine the patient’s usual temperature to
evaluate the degree of temperature elevation. Heart rate and
,respiratory rate increase with temperature. The presence of
diaphoresis may contribute to fluid volume deficit from
hyperthermia.
A clinic nurse assesses a patient who reports a loss of appetite
and a 15-pound weight loss since 2 months ago. The patient is 5
feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows
signs of depression and does not have a good understanding of
foods to eat for proper nutrition. The nurse makes the nursing
diagnosis of imbalanced nutrition: less than body requirements
related to reduced intake of food. For the goal of, "Patient will
return to baseline weight in 3 months," which of the following
outcomes would be appropriate? (Select all that apply.)
A. Patient will discuss source of depression by next clinic visit.
B. Patient will achieve a calorie intake of 2400 daily in 2 weeks.
C. Patient will report improvement in appetite in 1 week.
D. Patient will identify food protein sources. Correct Answer
B. Patient will achieve a calorie intake of 2400 daily in 2 weeks.
C. Patient will report improvement in appetite in 1 week.
With the related factor of reduced intake of food, the outcomes
should focus on behaviors that reflect an increase in intake. Thus
achieving an increase in calories and an improved appetite for
food would be appropriate. The patient’s depression
probably contributes to the loss of appetite, but being able to
discuss the source of depression is not an outcome for improving
her baseline weight. Being able to identify protein sources
would improve any knowledge deficit the patient might have but
would not help her gain weight.
, A female patient reports that she is experiencing burning on
urination, frequency, and urgency. The nurse notes that a clean-
voided urine specimen is markedly cloudy. The probable cause
of these symptoms and findings is:
A. Cystitis.
B. Hematuria.
C. Pyelonephritis.
D. Dysuria. Correct Answer A. Cystitis
Urine is cloudy in cystitis because of bacterial and white cells.
A goal specifies the expected behavior or response that
indicates:
A. The specific nursing action was completed.
B. The validation of the nurse's physical assessment.
C. The nurse has made the correct nursing diagnoses.
D. Resolution of a nursing diagnosis or maintenance of a healthy
state. Correct Answer D. Resolution of a nursing diagnosis or
maintenance of a healthy state.
The success in meeting a goal is reflected in achieving expected
outcomes—the physiological responses or behaviors that
indicate that a nursing diagnosis has been resolved and the
patient's health is improving.
A group of nurses is discussing the advantages of using
computerized provider order entry (CPOE). Which of the
following statements indicates that the nurses understand the
major advantage of using CPOE?
A. "CPOE reduces transcription errors."
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