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fourth semester test answers[1]

fourth semester test answers[1]

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05/09/2014

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Daytona Beach Community College
Department of Nursing
NUR 2744 Practice Exam ANSWERS/Rationale

2744 ANSWERS and RATIONALE
1. A (these signs and symptoms may be applied to several problems.
Obtaining a client history
would assist with establishing the cause of the problem).

n B\u2014the first thing to do is speak with the patient before invasive procedures
although you
will likely obtain serum electrolytes at a later time
n C\u2014as with patients with SIADH, peripheral edema may not be present if

fluid is in
intracellular spaces also we do not yet know how much weight gain over
how long.

n D\u2014The patient presents with no GI symptoms save for nausea. More

information is
needed to determine cause.
2. D\u2014the patient has had surgery known to cause DI. The question states DI
is present.
Appropriate treatment is to notify the physician of the increased urine output
and anticipate
replacement of vital fluids.

n A-- Urine has already been assessed for 2 hours, to assess for a longer
period delaying
fluid replacement may be harmful to the patient.
n B\u2014The patient will most likely show changes in urine osmolality and

sodium. Urine
Acetone is not important in the DI patient. These changes will not affect
treatment and
waiting for results to treat may be harmful

nC\u2014the patient will most likely show changes in serum electrolytes and

osm. These
changes will not affect treatment and waiting for results may be harmful to
the patient.
3. D\u2014In a patient with cardiogenic shock, you should anticipate initial
administration of IV Fluids
or fluid volume expanders such as plasmanex (normal serum albumin) to
increase cardiac output
by increasing myocardial muscle fiber stretch which increases contractility.

n A\u2014you should discontinue nitrates or other drugs that reduce blood
volume, preload, or
myocardial fiber stretching.
n B\u2014You should not administer Metoprolol (lopressor) because it may
decrease
contractility and may worsen shock. This drug also lowers blood pressure.
n C\u2014Morphine decreases preload hence decreasing contractility.

4. B\u2014This statement avoids inflammatory accusations and reinforces
positive behavior. It also
communicates the team leader\u2019s expectation that everyone will follow the
floating requirement.

n A\u2014This statement is inflammatory and \u2018never\u2019 is usually an exaggeration.
n C\u2014This statement is apologetic and confrontational.
n D\u2014This statement offers a false promise when floating requests are likely

to occur again,
http://faculty.dbcc.edu/health/nursing/ff2744answers.htm (1 of 9)10/6/2005 10:20:37 AM
Daytona Beach Community College

this statement may destroy a trusting relationship with the team leader.
5. C\u2014the halo\u2019s wrench and tool kit should be available at all times and
should be visible in the
room in case the chest plate must be removed for CPR

n A\u2014Logrolling the patient is no longer necessary as the halo traction device
stabilizes the
fracture with movement.
n B\u2014Keeping the HOB at 30 to 45 degrees is not necessary for patients in
halo traction
devices.
n D\u2014The stem of the question identifies no risks for aspiration hence this

invasive
procedure is not necessary and could cause harm.
6. B\u2014Recurring chest pain 12 hours post MI indicates extension of the MI.

To verify, the nurse
should obtain a 12 lead EKG and notify the physician of a change in
condition
n A\u2014recurring chest pain is not a sign of reperfusion
n C\u2014administration of a thrombolytic would require a physician\u2019s order as
does the heparin.
n D\u2014While morphine sulfate may increase oxygen delivery and decrease
sensation of pain,

it requires an order and nothing in the stem indicates that an order for
lidocaine is
warranted.
7. D\u2014Bladder distention or other similar stimuli are the trigger for this
spinal cord response after
spinal shock. Monitoring the Foley cath for patency can prevent an episode
from occurring.

n A\u2014chloral hydrate is a sedative which is not indicated for this patient
n B\u2014laboratory findings will not predict an event as it is caused by a
physical stimulus
n C\u2014the patient should be repositioned every 2 hours to prevent skin lesions,

keeping the
patient in trendelenberg position will not help prevent an episode and may
potentially be
harmful.
8. C\u2014The fundamental problem with pulmonary edema is that the patient\u2019s
lungs are fluid
overloaded making exchange of gasses at the alveolar level very difficult if
not impossible. If the
patient is not breathing he will die making this the highest priority diagnosis

n A\u2014The problem is at the alveolar level and makes the exchange of gasses

impossible.
Changing the breathing pattern will not help, we must get to the fundamental
problem.

n B\u2014While the patient would definitely have a nursing diagnosis of anxiety,
this is not the
priority at this time
n D\u2014The patient has a fluid volume overload, not deficit.

9. A\u2014post intubation, it is most important to assess for bilateral breath
sounds first. The
endotracheal tube may have been inserted too far and traveled down the
right main stem
bronchus where it could cause a tension pneumothorax.

n C-D\u2014while all of these are relative to the intubated patient, it is most

important to assess
breath sounds before doing any of these.
10. C\u2014while some of the other tests are certainly indicative of DIC, the
FDP and D-Dimer are
specific to DIC and these levels would indicate a positive finding of DIC.

n A, B, D\u2014while these could indicate DIC, they are less specific for DIC

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