Exam 1: NUR2755/ NUR 2755 (Latest 2023 / 2024) Multidimensional Care IV |Questions and Verified Answers| 100% Correct| Graded A- Rasmussen

Exam 1: NUR2755/ NUR 2755 (Latest 2023 /

2024) Multidimensional Care IV |Questions

and Verified Answers| 100% Correct|

Graded A- Rasmussen

Q: The nurse on the telemetry unit has just received the a.m. shift report. Which client should

the nurse assess first?

1. The client diagnosed with myocardial infarction who has an audible S3 heart

sound.

2. The client diagnosed with congestive heart failure who has 4+ sacral pitting

edema.

3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.

4. The client with chronic renal failure who has an elevated creatinine level.

Answer:

1. The client diagnosed with myocardial infarction who has an audible S3 heart

sound.

An audible S3 indicates left ventricular heart failure and the nurse must assess this client first

because it is an emergency situation

Q: The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a

telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

1. Assist the client to go down to the smoking area for a cigarette.

2. Transport the client to the intensive care unit via a stretcher.

3. Provide the client going home discharge-teaching instructions.

4. Help position the client who is having a portable x-ray done.

Answer:

4. Help position the client who is having a portable x-ray done.

Q: The charge nurse is making shift assignments for the medical floor. Which client should be

assigned to the most experienced registered nurse?

1. The client diagnosed with congestive heart failure who is being discharged in the

morning.

2. The client who is having frequent incontinent liquid bowel movements and

vomiting.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood

pressure of 94/62.

4. The client who is complaining of chest pain with inspiration and a no

Answer:

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood

pressure of 94/62.

this client is is exhibiting signs and symptoms of shock, the client is becoming unstable & needs

an experienced nurse.

Q: The client diagnosed with congestive heart failure is complaining of leg cramps at night.

Which nursing interventions should be implemented?

1. Check the client for peripheral edema and make sure the client takes a diuretic

early in the day.

2. Monitor the client's potassium level and assess the client's intake of bananas and

orange juice.

3. Determine if the client has gained weight and instruct the client to keep the legs

elevated.

4. Instruct the client to ambulate frequently and perform cal

Answer:

2. Monitor the client's potassium level and assess the client's intake of bananas and

orange juice.

The probable cause of leg cramping is potassium excretion as a result of diuretic medications.

Bananas and orange juice are high in potassium for a patient on diuretics.

Q: The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a

client diagnosed with congestive heart failure. Which intervention should the nurse implement to

assist the client to achieve this outcome?

1. Measure intake and output.

2. Provide two (2)-g sodium diet.

3. Weigh client daily.

4. Plan for frequent rest periods.

Answer:

4. Plan for frequent rest periods.

Scheduling rest periods allows the client to participate in his or her own care and addresses a

desired outcome.

Q: Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a

myocardial infarction?

1. Creatine kinase (CK-MB).

2. Lactate dehydrogenase (LDH).

3. Troponin.

4. White blood cells (WBCs).

Answer:

3. Troponin

Q: Along with persistent, crushing chest pain, which signs/symptoms would make the nurse

suspect that the client is experiencing a myocardial infarction?

1. Midepigastric pain and pyrosis.

2. Diaphoresis and cool clammy skin.

3. Intermittent claudication and pallor.

4. Jugular vein distention and dependent edema.

Answer:

2. Diaphoresis and cool clammy skin.

Diaphoresis is a systemic reaction to the MI. The body vasoconstrics to shunt blood from the

periphery to the trunk of the body and causes cold, clammy skin.

Q: The client diagnosed with rule-out myocardial infarction is experiencing chest pain while

walking to the bathroom. Which action should the nurse implement first?