Exam 1: NUR2755/ NUR 2755 (New 2023 / 2024) Multidimensional Care IV |Questions and Verified Answers| 100% Correct| Graded A- Rasmussen
Exam 1: NUR2755/ NUR 2755 (New 2023 /
2024) Multidimensional Care IV |Questions
and Verified Answers| 100% Correct|
Graded A- Rasmussen
QUESTION
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing
chest pain. Which interventions should the nurse implement? Select all that apply.
- Administer morphine intramuscularly.
- Administer an aspirin orally.
- Apply oxygen via a nasal cannula.
- Place the client in a supine position.
- Administer nitroglycerin subcutaneously.
Answer: - Administer an aspirin orally.
- Apply oxygen via a nasal cannula.
1 is incorrect because morphine is administered IV not IM
5 Is incorrect because nitro is given sublingually, not subcutaneously
QUESTION
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive
care. Which referral would be most appropriate for the client?
- Social worker.
- Physical therapy.
- Cardiac rehabilitation.
- Occupational therapy.
Answer: - Cardiac rehabilitation.
QUESTION
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of
chest pain. Which intervention should the nurse implement first?
- Medicate the client with intravenous morphine.
- Assess the client’s chest dressing and vital signs.
- Encourage the client to turn from side to side.
- Check the client’s telemetry monitor.
Answer: - Assess the client’s chest dressing and vital signs.
4 is incorrect because a nurse should assess the patient first, not a machine
QUESTION
The client diagnosed with a myocardial infarction is six (6) hours post-right femoral
percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which
assessment data would require immediate intervention by the nurse?
- The client is keeping the affected extremity straight.
- The pressure dressing to the right femoral area is intact.
- The client is complaining of numbness in the right foot.
- The client’s right pedal pulse is 3+ and bounding.
Answer: - The client is complaining of numbness in the right foot.
QUESTION
The intensive care department nurse is assessing the client who is 12 hours post-myocardial
infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse
implement? - Notify the health-care provider immediately.
- Elevate the head of the client’s bed.
- Document this as a normal and expected finding.
- Administer morphine intravenously.
Answer: - Notify the health-care provider immediately.
Notifying the health care provider immediately is necessary because S3 indicates left ventricular
failure and is potentially life threatening
QUESTION
The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial
infarction. Which assessment data would cause the nurse to question administering this
medication? - The client’s apical pulse is 64.
- The client’s calcium level is elevated.
- The client’s telemetry shows occasional PVCs.
- The client’s blood pressure is 90/62.
Answer: - The client’s blood pressure is 90/62.
the clients BP is low, and a calcium channel blocker would lower the pressure more.
QUESTION
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive
personnel (UAP) is encouraging the client to move the legs. Which action should the nurse
implement? - Instruct the UAP to stop encouraging the leg movements.
- Report this behavior to the charge nurse as soon as possible.
- Praise the UAP for encouraging the client to move legs.
- Take no action concerning the UAP’s behavior.
Answer: - Praise the UAP for encouraging the client to move legs.
The nurse should praise and encourage UAP’s to participate in the client’s care. Clients on
bedrest are at risk for DVT and moving the legs helps prevent this from occurring.
QUESTION
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A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching?
Roast chicken and white rice
Which menu choice by the patient with diverticulosis is best for preventing diverticulitis?
Navy bean soup and vegetable salad
A nurse is caring for a client who has Crohn’s disease. Which of the following food choices would follow the recommended diet?
Toast with jelly
A nurse is assessing a patient’s colostomy during an ostomy appliance change and finds that the patient’s stoma is reddish pink and moist with slight bleeding when the mucosa is rubbed. Which action should the nurse take?
These are normal findings
Which finding is likely in the nurse’s assessment of a patient who has a large bowel obstruction?
Abdominal distention
What is the first intervention for a client experiencing MI?
Administer oxygen
You’re preparing to help the neurologist with conducting a Tensilon test. Which antidote will you have on hand in case of an emergency?
Atropine
The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a patient who is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis. Which findings after the administration of Edrophonium would represent the patient has myasthenia gravis?
The patient experiences improved muscle strength.
A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)
Nausea
Tachycardia
Diaphoresis
The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102 F. Which intervention should the nurse implement?
Notify the health care provider
A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first?
infuse metronidazole (Flagyl) 500 mg IV
A patient with Crohn’s disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?
Fever
A young woman with Crohn’s disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. Which information will the nurse add to a teaching plan about UTIs for this patient that goes beyond a general teaching plan for UTIs?
Fistulas can form between the bowel and bladder.
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?
Oatmeal with cream
The nurse is admitting a patient with new-onset steatorrhea. Which question is most important for the nurse to ask? .
“Have you had a recent weight loss?”
Which question from the nurse would help determine if a patient’s abdominal pain might indicate irritable bowel syndrome (IBS)?
“How long have you had abdominal pain?”
You receive a doctor’s order for a patient to take Aspirin EC by mouth daily. The patient has the following medication history: diabetes type 2, peripheral vascular disease, and a permanent
ileostomy. What is your next nursing action?
Hold the medication and notify the doctor the
patient has an ileostomy.
Patients with ileostomies should be given which instruction?
“Do not take enteric-coated tablets.”
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
apply water soluble ointment to nares and lips
A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor fo
abdominal distension
Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)
Drain and measure the output from the ostomy.
A patient with irritable bowel syndrome (IBS) receiving alosetron develops constipation. Which nursing intervention is appropriate
Stop the medication immediately
A 29-year-old woman has been prescribed alosetron (Lotronex) for irritable bowel syndrome. Before starting the drug therapy, the nurse will advise the client about which adverse effect(s)?
Constipation
The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action?
don gloves and gown before entering patient’s room
fter several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?
Place the patient on contact precautions
Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)?
Encourage the patient to express concerns and ask questions about IBS
The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to:
administer IV fluids
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? (Select All that Apply)
- administer aspirin orally
- apply oxygen via nasal cannula
Which admission prescription written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?
Draw blood cultures from two sites
A nurse is assessing a patient who has a chest tube in place attached to a closed-chest water-seal drainage system. When the nurse palpates the area around the chest-tube insertion site, she is checking for?
subcutaneous emphysema
*Acute exacerbations of ulcerative colitis, which action should be taken first?
-electrolyte imbalance (loss of K+)
*You’re teaching a pt who has a new colostomy, which outcome would you expect from the pt
-report of empowerment
*A nurse is assessing a CT who has ulcerative colitis and severe diarrhea, which assessment should the nurse complete first?
-hr & rhythm
*Your pt is receiving sulfasalazine, which would be most concerning for you?
-decreased urine output
*Pt has diverticulosis, admitted for diverticulitis 3 days ago… which statement by your pt would indicate additional teaching?
-I will take a laxative nightly at bedtime to avoid constipation (increase bowel pressure
*You have a pt in the ED that presents with MI, which prescription would you take first?
-administer o2 therapy
*Pt is prescribed Alosetron for IBS-D, which assessment question should you ask the CT?
-Have you been experiencing constipation
*With medication Bromocriptine, which teaching should you include?
-Rise slowly when getting up
*Pt has new colostomy, what should the nurse tell their to expect?
-Small amount of bleeding may be present (Fairly new)
*Which statement by the pt indicates further teaching for colostomy care?
-I will be certain to take enterocoated med (can cause blockage)
*Pt is applying a nitroglycerin patch, what information should the nurse educate the pt on?
-Apply patch to hairless area & rotate sites
-Remove patch 10-12 hrs daily (12 on / 12 off to prevent intolerance)
-Apply a new patch each morning
*A nurse is admitting a pt with steatorrhea, what question should the nurse ask?
-Have you noticed recent weight loss
sources;
https://www.gcu.edu/
https://yaveni.com/
https://www.rasmussen.edu/