Physiological Adaptation

Which cardiac enzyme is represented by the dot/dash alternating () line?

Which cardiac enzyme is indicated by the dashed ( ) line?

Which cardiac enzyme is noted by the solid line ( )?

The nurse auscultates an opening snap after the second heart sound when the stethoscope is placed to the left of the lower sternum. Which additional heart sound does the nurse expect to hear?

The nurse is reviewing the admission assessment of a new patient and notes a IV/VI murmur was heard during auscultation of the heart. The nurse anticipates making which assessment?

The nurse is performing the patient’s initial cardiovascular assessment and palpates a heave over the location where a loud murmur is auscultated. Which terminology is most appropriate for the nurse to report this finding to the provider?

Which phonocardiogram tracing indicates a common heart condition associated with prematurity?

The patient is scheduled for an aortic valvuloplasty. The nurse anticipates auscultation of the heart will reveal which pattern?

The patient with Marfan syndrome presents with difficulty breathing in the supine position and fatigue. Upon palpation, a heave is noted. The nurse anticipates auscultating which heart sound?

The nurse notes these heart sounds on auscultation of a 65-year-old man: The nurse reviews the patient’s medical record for history of which conditions associated with these heart sounds? Select all that apply.

The 1.5-kg preterm neonate in the neonatal intensive care unit is intubated and mechanically ventilated. The ventilator is set to deliver a tidal volume of 6 mL with each breath. On day of life 1, the patient’s peak inspiratory pressure was 15 mm Hg. On day of life 3, the patient’s peak inspiratory pressure is 22 mm Hg. How does the nurse interpret this information?

The nurse is caring for the infant hospitalized prior to surgery for intussusception. The nurse anticipates the patient’s stool will have which appearance?

The 6-month-old neonate is brought to the emergency department (ED). The parents state, “She is just so lethargic. Anything she eats, she vomits. Her vomit was normal initially, but now it’s dark green. Also, her stool has turned to a dark red, jelly-like consistency.” The nurse palpates the patient’s abdomen, expecting to make which assessment?

The patient with kidney failure is scheduled to undergo the placement of a peritoneal dialysis catheter. Which instruction does the nurse give the patient?

The patient found unresponsive in the park is determined to be in ventricular fibrillation. After cardiopulmonary resuscitation and defibrillation, the patient experienced return of spontaneous circulation. Initial survey upon arrival to the emergency department (ED) reveals a cachectic appearance and an edematous mass on the right forearm; upon palpation, the nurse palpates a thrill. The nurse is aware life-saving measures will have which aim?

The pediatric patient has simple otitis externa (swimmer’s ear) and is afebrile. The nurse prepares educational materials for which treatment?

The nurse expects the patient with severe hypomagnesemia to also show signs of which deficiency? Select all that apply.

The patient with an automated implantable cardioverter-defibrillator (AICD) experiences a discharge of the device. The nurse reports this event to the provider with the knowledge that the patient experienced which arrhythmia?

The nurse provides which instruction to the patient prescribed incentive spirometry following lower limb orthopedic surgery? 

The obstetrician performs a pelvic exam and reports that the 39-weeks-gestation woman is at 4 cm and zero station. The nurse interprets the fetus's head to be in which location? 

During assessment of the patient with an ileostomy, the nurse discovers that the opening of the pouch is about 5/8” inch larger than the stoma. This patient is at increased risk for which adverse outcome?

The nurse is providing education to the patient with an ileostomy. Which statement by the patient suggests additional education is needed?

The patient receiving mechanical ventilation opens the eyes, attempts to talk, and appears to be in distress. Which action does the nurse take first?

The nurse in the intensive care unit (ICU) hears repeated high pressure alarms from the mechanical ventilator of the intubated patient and suspects which condition?

The nurse in the intensive care unit (ICU) hears repeated low pressure alarms from the ventilator of the intubated patient and suspects which condition?

Which statement describes the term “viral load” as it relates to human immunodeficiency virus (HIV)?

Which interventions does the nurse include in the plan of care for the 2-day-old infant who requires phototherapy for hyperbilirubinemia? Select all that apply.

The nurse is using the Finnegan scoring system to assess a neonate for opioid withdrawal. The first score is 9 and the second score is 14. Which statement is accurate?

The nurse is caring for a woman who gave birth via forceps delivery within the last 24 hours. The patient describes significant rectal pressure but has had normal bowel movements. The nurse reports the finding to the provider with concerns for which postpartum complication?

Which statement by the patient recently diagnosed with Crohn's disease indicates more teaching is needed? 

A high school wide receiver suffered substantial head trauma during a tackle. The school nurse is concerned about concussion. The nurse provides which information to the adolescent and parents? Select all that apply.

Which report from the ophthalmologist indicates the patient with type 2 diabetes mellitus is experiencing early signs of poor glycemic control?

The patient presents to the emergency department (ED) complaining of sudden onset loss of vision in the right eye. The patient denies recent trauma or other symptoms. The nurse anticipates which report from the ophthalmoscopic exam of the retina?

The nurse learns the patient has a defect in the cone cells in the retina. The nurse anticipates the patient to have which vision?

The patient with laryngitis requests tips on nonpharmacological symptom management. The nurse makes which suggestion?

The patient has right ventricular hypertrophy on echocardiogram. The nurse plans care to focus interventions for which effect?

The patient with chronic obstructive pulmonary disorder has an oxygen saturation of 89% on room air. Which order does the nurse clarify with the provider?

The nurse planning care for the patient with left-sided heart failure understands that treatment centers around which treatment goal?

The patient in heart failure exhibits the following respiratory pattern. The nurse uses which term to document the patient’s respiratory effort?

The nurse reviews the provider note about a new patient and notes the patient’s skin is described as plethoric. Which assessment is consistent with this description?

The patient with Raynaud’s phenomenon presents with which characteristic during an exacerbation?

The patient with Raynaud’s phenomenon has received teaching on how to manage the disorder. Which statement by the patient indicates a need for further teaching?

The nurse is providing education to the patient recently diagnosed with Raynaud’s phenomenon. Which information does the nurse include in teaching?

Which pulse is assessed by palpating the lateral side of the wrist?

Which term is used to denote a weak, thready pulse?

Which wound most likely requires healing by second intention?

The nurse receives report and learns the patient has a wound that is healing by third intention. Which intervention is most important to include in the patient’s care plan?

The 60-year-old patient who was recently laid off from his factory job of 38 years presents to the emergency department complaining of severe superficial pain over the flank. Which assessment will be most important for diagnosis?

The patient with shingles presents to the clinic for reassessment following treatment. The nurse asks the patient to perform which action to assess for complications of the condition?

The 24-year-old patient presents to the emergency department complaining of malaise and intractable sore throat with onset 24 hours previously. Upon assessment, the nurse notes swollen cervical lymph nodes and a temperature of 39.3°C. The patient denies nasal discharge or cough. Which question by the nurse is most important?