NSG 3800 - Exam 2 Questions With Complete Solutions
10. A patient with a decreased level of consciousness is in a
recumbent position. How should the nurse best assess the lung
fields for a patient in this position?
A) Inform that physician that the patient is in a recumbent
position and anticipate an order for a portable chest x-ray.
B) Turn the patient to enable assessment of all the patients lung
fields.
C) Avoid turning the patient, and assess the accessible breath
sounds from the anterior chest wall.
D) Obtain a pulse oximetry reading, and, if the reading is low,
reposition the patient and auscultate breath sounds. Correct
Answer B
Feedback: Assessment of the anterior and posterior lung fields is
part of the nurses routine evaluation. If the patient is recumbent,
it is essential to turn the patient to assess all lung fields so that
dependent areas can be assessed for breath sounds, including the
presence of normal breath sounds and adventitious sounds.
Failure to examine the dependent areas of the lungs can result in
missing significant findings. This makes the other given options
unacceptable.
30. A 79-year-old man is admitted to the medical unit with
digital gangrene. The man states that his problems first began
when he stubbed his toe going to the bathroom in the dark. In
addition to this trauma, the nurse should suspect that the patient
has a history of what health problem?
A) Raynauds phenomenon
B) CAD
C) Arterial insufficiency
,D) Varicose veins Correct Answer C
Feedback:
Arterial insufficiency may result in gangrene of the toe (digital
gangrene), which usually is caused by trauma. The toe is
stubbed and then turns black. Raynauds, CAD and varicose
veins are not the usual causes of digital gangrene in the elderly.
30. A medical nurse has admitted four patients over the course
of a 12-hour shift. For which patient would assessment of ankle-
brachial index (ABI) be most clearly warranted?
A) A patient who has peripheral edema secondary to chronic
heart failure
B) An older adult patient who has a diagnosis of unstable angina
C) A patient with poorly controlled type 1 diabetes who is a
smoker
D) A patient who has community-acquired pneumonia and a
history of COPD Correct Answer C
Feedback:
Nurses should perform a baseline ABI on any patient with
decreased pulses or any patient 50 years of age or older with a
history of diabetes or smoking. The other answers do not apply.
30. A nurse has written a plan of care for a man diagnosed with
peripheral arterial insufficiency. One of the nursing diagnoses in
the care plan is altered peripheral tissue perfusion related to
compromised circulation. What is the most appropriate
intervention for this diagnosis?
A) Elevate his legs and arms above his heart when resting.
B) Encourage the patient to engage in a moderate amount of
exercise.
C) Encourage extended periods of sitting or standing.
,D) Discourage walking in order to limit pain. Correct Answer
B
Feedback:
The nursing diagnosis of altered peripheral tissue perfusion
related to compromised circulation requires interventions that
focus on improving circulation. Encouraging the patient to
engage in a moderate amount of exercise serves to improve
circulation. Elevating his legs and arms above his heart when
resting would be passive and fails to promote circulation.
Encouraging long periods of sitting or standing would further
compromise circulation. The nurse should encourage, not
discourage, walking to increase circulation and decrease pain.
30. A nurse in a long-term care facility is caring for an 83-year-
old woman who has a history of HF and peripheral arterial
disease (PAD). At present the patient is unable to stand or
ambulate. The nurse should implement measures to prevent
what complication?
A)Aoritis
B) Deep vein thrombosis
C) Thoracic aortic aneurysm
D) Raynauds disease Correct Answer B
Feedback:
Although the exact cause of venous thrombosis remains unclear,
three factors, known as Virchows triad, are believed to play a
significant role in its development: stasis of blood (venous
stasis), vessel wall injury, and altered blood coagulation. In this
womans case, she has venous stasis from immobility, vessel
wall injury from PAD, and altered blood coagulation from HF.
The cause of aoritis is unknown, but it has no direct connection
to HF, PAD, or mobility issues. The greatest risk factors for
, thoracic aortic aneurysm are atherosclerosis and hypertension;
there is no direct connection to HF, PAD, or mobility issues.
Raynauds disease is a disorder that involves spasms of blood
vessels and, again, no direct connection to HF, PAD, or mobility
issues.
30. A nurse in the rehabilitation unit is caring for an older adult
patient who is in cardiac rehabilitation following an MI. The
nurses plan of care calls for the patient to walk for 10 minutes 3
times a day. The patient questions the relationship between
walking and heart function. How should the nurse best reply?
A) The arteries in your legs constrict when you walk and allow
the blood to move faster and with more pressure on the tissue.
B) Walking increases your heart rate and blood pressure.
Therefore your heart is under less stress.
C) Walking helps your heart adjust to your new arteries and
helps build your self-esteem.
D) When you walk, the muscles in your legs contract and pump
the blood in your veins back toward your heart, which allows
more blood to return to your heart. Correct Answer D
Feedback:
Veins, unlike arteries, are equipped with valves that allow blood
to move against the force of gravity. The legs have one-way
bicuspid valves that prevent blood from seeping backward as it
moves forward by the muscles in our legs pressing on the veins
as we walk and increasing venous return. Leg arteries do
constrict when walking, which allows the blood to move faster
and with more pressure on the tissue, but the greater concern is
increasing the flow of venous blood to the heart. Walking
increases, not decreases, the heart pumping ability, which
increases heart rate and blood pressure and the hearts ability to
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