Nursing a Concept Based Approach Test Bank

Questions 14

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Nursing a Concept Based Approach Test Bank Questions

Question 1 of 5

The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)?

Correct Answer: D

Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.

Question 2 of 5

Following a kidney transplant, the nurse notes that a patient�s urine is cloudy. What should the nurse do about this finding?

Correct Answer: A

Rationale: Cloudy urine following a kidney transplant may be a common occurrence and could be due to various factors such as dehydration, medication side effects, or the presence of mucus, cells, or proteins in the urine. The nurse should first record the finding and then further assess the patient by checking for other signs and symptoms like pain, fever, or abnormal odors in the urine. If the cloudy urine is persistent or accompanied by other concerning symptoms, then the nurse should notify the physician for further evaluation. However, initially recording the finding allows for documentation and monitoring of the patient's condition, providing a baseline for further assessment and intervention if necessary. It is important to remember that cloudy urine alone may not always indicate a serious issue, but thorough assessment and documentation are essential steps in ensuring the patient's well-being.

Question 3 of 5

The nurse is conducting a physical examination of a patient�s renal system. What assessment would the nurse use to assess the hydration status of a patient?

Correct Answer: A

Rationale: Palpation for skin turgor is used to assess the hydration status of a patient. Skin turgor is a measure of the skin's elasticity and hydration level. When a patient is well-hydrated, their skin will have good turgor, meaning it will return to its normal position quickly after being pinched. On the other hand, in a dehydrated patient, the skin will have poor turgor and will not return to its normal position promptly. Therefore, assessing skin turgor is a valuable tool for determining a patient's hydration status during a physical examination of the renal system. Palpation of both kidneys, auscultation of renal arteries, and percussion for dullness over the bladder are not specifically related to assessing hydration status.

Question 4 of 5

The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)?

Correct Answer: D

Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.

Question 5 of 5

The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.

Correct Answer: A

Rationale: 1. A palpable thrill in the pulmonic area is a common finding in children with tetralogy of Fallot (TOF). This sensation is caused by turbulent blood flow across the pulmonic valve due to the structural abnormalities present in TOF.

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