Aha Exam 2 Revised

8/2/2019 Aha Exam 2 Revised

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Tacara Berrain

Submitted 4/22/12 5:02 PM

Name Nur 223 Adv HA Exam 2 Apr 10, 2012

Status CompletedScore 92 out of 100 points

Instructions

Question 1

2 out of 2 points

When assessing an IV site, which of the following indicacte abnormal findings?

Answer

Selected Answers:swelling

redness

cool skin

Correct Answers:swelling

redness

cool skin

Question 2

0 out of 2 points

Select all of the following that are functions of the integumentary system.

Answer

Selected Answers:


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functions to sense tempereature, pain, and touch

helps to regulate temperature of the body

vitamin D production

Correct Answers:

functions to sense tempereature, pain, and touch

helps to regulate temperature of the body

vitamin D production

protection against trauma and infection

protects from loss of water and electrolytes

Question 3

0 out of 2 points

A full thickness pressure ulcer that goes throw to bone is classified as a stage______ wound.

Answer

Selected Answer:

IV

Correct Answer:I

Question 4

2 out of 2 points


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Match the description with the term.

Answer

Question Correct Match Selected Match

skin that has tenting D.

dehydration

D.

dehydration

skin that has itching, wheals A.allergic reaction

A.allergic reaction

skin that is red, swollen, tender, and warm C.

inflamed

C.

inflamed

skin that has itching B.

pruritus

B.

pruritus

Question 5

2 out of 2 points

Match the description to the appropriate definition.

Answer


skin wound that is draining

serous fluid

B.

clear yellow

B.

clear yellow

skin wound that is drainagesanguinous fluid

A.bloody

A.bloody

skin wound that is draining

sero-sanguineous fluid

D.

blood mixed with

yellow, clear exudate

D.

blood mixed with

yellow, clear exudate

skin wound that is drainingpurulent exudate

C.infected

C.infected

Question 6

2 out of 2 points

Select all of the following that place the patient at risk for developing impaired

skin integrity.

Answer

Selected Answers:tanning in the sun between the hours of 11am and 3pm


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patient immobilized due to a hipfracture

decreased albumin and protein levels in the blood

frequent or constant exposure to moisture

Correct Answers:tanning in the sun between the hours of 11am and 3pm

patient immobilized due to a hipfracture

decreased albumin and protein levels in the blood

frequent or constant exposure to moisture

Question 7

2 out of 2 points

Match the associated lesion with the name or treatment.Answer


C.

caused by herpes

virus

C.

caused by herpes

virus

D.ringworm treat with

griseofulvin-monitorliver enzymes

D.ringworm treat with

griseofulvin-monitorliver enzymes


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A.

immunocompromised

patients, treat withnystatin swish and

swallow

A.

immunocompromise

patients, treat withnystatin swish and

swallow

B.

after a course of

antibiotics

B.

after a course of

antibiotics

Question 8

2 out of 2 points

Your patient has an open lesion on his left ear.

Select all of the following that would support a nursing diagnosis of "Impaired skinintegrity" related to ineffective tissue perfusion.

Answer

Selected Answers:patient has been lying on left side for 4 hours without turning

patient has HR 56

patient has BP 90/50

Correct Answers:

patient has been lying on left side for 4 hours without turning

patient has HR 56

patient has BP 90/50

Question 9

2 out of 2 points


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Select all of the following that are abnormal findings in the skin.

Answer

Selected Answers:jaundiced

cyanotic

pale

Correct Answers:jaundiced

cyanotic

pale

Question 10

2 out of 2 points

Match the intervention with the rationale for a client with impaired skin integrity.Answer


reposition every

90 minutes to 2

hours

A.

removes pressure and allows

normal blood return response

A.

removes pressure and allows

normal blood return response

keep skin dryand clean, avoid

rubbingreddened areas

D.moisture softens the skin ;

rubbing in an area ofnonblanching erythema(doesn't turn white when you

push in on it) will cause

further tissue damage

D.moisture softens the skin ;

rubbing in an area ofnonblanching erythema(doesn't turn white when you

push in on it) will cause

further tissue damage

elevate head ofthe bed no more

C.the higher the head of the

C.the higher the head of the


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than 30 degrees bed, the more likely shearing

forces will be present making

the wound worse

bed, the more likely shearing

forces will be present making

the wound worse

use a moisture

barrier ointmentover the wound

at least 3 times a

day

B.

will provide moisture to thewound which encourages

healing; will prevent the

sheets from rubbing on thearea thus decreasing friction

B.

will provide moisture to thewound which encourages

healing; will prevent the

sheets from rubbing on thearea thus decreasing friction

Question 11

2 out of 2 points

Select all of the following that are true with findings in assessing the skin.

AnswerSelectedAnswers: white patches on a person of genetic African descent are known as

vitiligo

jaundice, yellowing, is associated with liver or bile disease or

hemolytic (breaking apart of red blood cells) anemia whichmanifests as increased bilirubin levels

CorrectAnswers:

white patches on a person of genetic African descent are known as

vitiligo

jaundice, yellowing, is associated with liver or bile disease or

hemolytic (breaking apart of red blood cells) anemia which

manifests as increased bilirubin levels

Question 12

2 out of 2 points

A patient has an open lesion on the heal. Select all of the following that supports a

nursing diagnosis of "Impaired skin integrity related to impaired nutrition."Answer


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Selected Answers:

albumin level of 1.5

patient is underweight and malnourished

Correct Answers:

albumin level of 1.5

patient is underweight and malnourished

Question 13

2 out of 2 points

Select all the following that are correct related to interventions/risk factors to

prevent pressure ulcers.

Answer

Selected

Answers: for a client with decreased mobility and poor nutrition -provide

adequate nutritional and fluid intake; consult a dietitian for nutritionalevaluation

to avoid friction and sheer, use a drawsheet and lift off surface;position at a 30 degree lateral turn; provide a trapeze to facilitate

movement

for a person with decreased sensory perception - assess pressure

points for signs of nonblanching reactive hyperemia (doesn't turnwhite, then red when released) and provide a pressure resdistribution

surface

for a person that is moist frequently - cleanse area and provide a

moisture barrier to the skin especially after incontinent episodes

Correct

Answers:

for a client with decreased mobility and poor nutrition -provide


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adequate nutritional and fluid intake; consult a dietitian for nutritional

evaluation

to avoid friction and sheer, use a drawsheet and lift off surface;

position at a 30 degree lateral turn; provide a trapeze to facilitatemovement

for a person with decreased sensory perception - assess pressurepoints for signs of nonblanching reactive hyperemia (doesn't turn

white, then red when released) and provide a pressure resdistribution

surface

for a person that is moist frequently - cleanse area and provide a

moisture barrier to the skin especially after incontinent episodes

Question 14

2 out of 2 points

To assess skin turgor in the elderly, pull the skinAnswer

Selected Answer:

on the chest

Correct Answer:

on the chest

Question 15

2 out of 2 points

Which of the following is a Stage II pressure ulcer?

Answer

Selected Answer:


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Correct Answer:

Question 16

2 out of 2 points

Select all of the following that are functions of the skin.Answer

Selected Answers:

sensory organ for touch

sensory organ for temperature

regulator of body temperature

Correct Answers:

sensory organ for touch

sensory organ for temperature

regulator of body temperature

Question 17

2 out of 2 points

Select all of the following that would support a nursing diagnosis of "Impaired skin

integrity related to infection".

Answer

Selected Answers:edges of wound red and warm, not approximated


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yellow, foul-smelling drainage from the wound

presence of wound or a break in skin integrity

Correct Answers:

edges of wound red and warm, not approximated

yellow, foul-smelling drainage from the wound

presence of wound or a break in skin integrity

Question 18

2 out of 2 points

Cool, clammy skin occurs when surface blood vessels constrict shunting blood tointerior organs.

Answer

Selected Answer: True

Correct Answer: True

Question 19

2 out of 2 points

Match the skin condition with the associated term.Answer


yellowish tent

to sclera and

skin

F.

liver or bile problem,

increased bilirubin, hemolyticanemia ( red blood cells split

apart and liver is unable to

process them quickly)

F.

liver or bile problem,

increased bilirubin, hemolyticanemia ( red blood cells split

apart and liver is unable to

process them quickly)

pale skin,nailbeds and

conjunctiva

C.anemia and decreased red

blood cells

C.anemia and decreased red

blood cells


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bluish tent to

skin

A.

problem with oxygenation

A.

problem with oxygenation

skin that is

"red as a beet"

B.

flushed skin with blood flow

and dilated vessels

B.

flushed skin with blood flow

and dilated vesselsskin that is

cold and

clammy

E.

skin with blood vessels

constricted and blood is

shunted to the inner organs

E.

skin with blood vessels

constricted and blood is

shunted to the inner organs

skin that is

black, necrotic

D.

dead skin that needs to be

debrided

D.

dead skin that needs to be

debrided

Question 20

2 out of 2 points

Match the description of the lesion with the description or treatment.Answer

QuestionCorrect

Match

Selected

Match

rounded area with intense itching caused by fungus,

commonly known as ringworm, treated withantifungal such as lotrimin or nystatin

B.

tinea

B.

tinea

painful recurring blusters caused by a virus with

shortening of symptoms treated by Acyclovir

D.

herpes

D.

herpes

linear, itching lesions caused by a mite - treat with

Kwell or lindane - contact isolation, wash clothing,bedding in hot water,

F.

scabies

F.

scabies

honey colored lesions caused by strep skin infection,

treat with antibiotic

C.

impetigo

C.

impetigo

head or body infestation caused by organisms that

leaves eggs known as nits - treat with Kwell, Rid, or

lindane and wash all clothes and bedding in hotwater- place in contact isolation

G.

lice

G.

lice

inflammation of skin caused by contqact with

material that one is allergic to- treat by excising orwith chemotherapeutic drugs

E.

contactdermatitis

E.

contactdermatitis

dark, irregular, elevated lesion with assymetric A. A.


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borders and variegated colors melanoma melanoma

Question 21

2 out of 2 points

Hemolytic anemia occurs when red blood cells lyse ( break apart) and liver cannot

process them quickly. Hemoglobin and other pigments are deposited in the skin

and the broken apart RBCs clump together in trying to get through the bloodvssels. Select all of the following that would be seen in a client with hemolytic

anemia.

Answer

Selected Answers:pain from clumping of the cells in the blood vessels

jaundice from deposition of bilirubin

Correct Answers:pain from clumping of the cells in the blood vessels

jaundice from deposition of bilirubin

Question 22

2 out of 2 points

A cardiac catherization is a procedure in which the catheter is inserted into theheart to obtain information about what is happening in the heart. Which of the

following should the nurse assess after the procedure?

Answer

SelectedAnswer:

assess the site for possible bleeding and check distal pulses to

assure blood flow to extremities

Correct

Answer:

assess the site for possible bleeding and check distal pulses toassure blood flow to extremities

Question 23


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2 out of 2 points

Select all of the following that are functions of bloodlAnswer

SelectedAnswers: helps regulate fluid/electrolyte and acid-base balance

transport metabolic wastes products from cells to lungs, liver,

and kidneys

transport nutrients from GI tract to cells

transport oxygen from lungs to cells

regulate body temperature

protects by combating invasion of pathogens and other foreign

substances

Correct

Answers:

helps regulate fluid/electrolyte and acid-base balance

transport metabolic wastes products from cells to lungs, liver,and kidneys

transport nutrients from GI tract to cells

transport oxygen from lungs to cells

regulate body temperature

protects by combating invasion of pathogens and other foreignsubstances


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Question 24

2 out of 2 points

Match the lymph nodes with the appropriate area for assessing them.

Answer


under the chin A.submental

A.submental

under the jaw E.

submandibular

E.

submandibular

infection in front of the ear B.

preauricular

B.

preauricular

infection in the back of the head C.occipital

C.occipital

infection in the lower arm D.

epitrochlear

D.

epitrochlear

infection in the breast F.

axillary

F.

axillary

Question 25

2 out of 2 points

Select all of the following that are clinical manifestations of anemia.Answer

Selected Answers:

fatigue

pallor

palpitations, dyspnea

Correct Answers:

fatigue


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pallor

palpitations, dyspnea

Question 26

2 out of 2 points

Fatigue is a subjective complaint with both acute and chronic illnesses. Select all

of the following that would be contributing factors in a nursing diagnosis offatigue.

AnswerSelected Answers:

sleep deprivation

stress

medication side effects

hemoglobin of 9 hematocrit of 30

Correct Answers:

sleep deprivation

stress

medication side effects

hemoglobin of 9 hematocrit of 30

Question 27


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0 out of 2 points

Select all of the following that the nurse would find in a patient with occlusivevenous disease in the leg.

Answer

Selected Answers:

cold extremity

brown, pigmented skin from deposits of hemoglobin in theskin

Correct Answers:warm extremity

brown, pigmented skin from deposits of hemoglobin in the

skin

Question 28

2 out of 2 points

Select all of the following that are clinical manifestations/descriptions of sickle cellanemia.Answer

Selected

Answers: genetic disease

sickling of cells causes clumping that blocks flow in the blood

vessels resulting in pain

illness and dehydration precipitates sickle cell crises

keep hydrated and treat pain

Correct


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Answers: genetic disease

sickling of cells causes clumping that blocks flow in the blood

vessels resulting in pain

illness and dehydration precipitates sickle cell crises

keep hydrated and treat pain

Question 29

2 out of 2 points

Select all of the following that are involved in blood clotting.

Answer

Selected Answers:

platelet aggregation

clotting factors such as prothrombin and thrombin

Correct Answers:

platelet aggregation

clotting factors such as prothrombin and thrombin

Question 30

2 out of 2 points

Select all of the following that are found in the normal physical assessment of the

cardiovascular system.Answer

Selected

Answers: + S1, S2 heart sounds


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PMI (point of maximal intensity) is palpable in 4th intercostal

space, midclavicular line

absence of murmurs

no pedal edema

Correct

Answers:

+ S1, S2 heart sounds

PMI (point of maximal intensity) is palpable in 4th intercostal

space, midclavicular line

absence of murmurs

no pedal edema

Question 31

2 out of 2 points

Select all of the following that would be found in an arterial occlusive disorder in

the legs. Think of what happens when an artery is blocked and blood can't getthrough.

Answer

Selected Answers:hairless area

decreased pulses

cold extremity distal to the occlusion

Correct Answers:


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hairless area

decreased pulses

cold extremity distal to the occlusion

Question 32

2 out of 2 points

When cells are injured, they release enzymes and biomarkers useful in thediagnosis of cardiac disease. Select all of the following that are correct related to

blood studies done to diagnose cardiac disease.Answer

SelectedAnswers: b-type natriuretic peptide (BNP) is levated in congested heart

failure

elevated homocysteine levels are used to predict risk of an

increased risk of a first cardiac event

elevated troponin and CK-MB (creatine kinase cardiac band) inheart attack

serum lipids - triglycerides, LDLs, cholesterol are elevated incoronary artery disease

c-reactive protein is elevated and is used to predict risk for

developing coronary artery disease

Correct

Answers:

b-type natriuretic peptide (BNP) is levated in congested heart

failure

elevated homocysteine levels are used to predict risk of an


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increased risk of a first cardiac event

elevated troponin and CK-MB (creatine kinase cardiac band) in

heart attack

serum lipids - triglycerides, LDLs, cholesterol are elevated in

coronary artery disease

c-reactive protein is elevated and is used to predict risk for

developing coronary artery disease

Question 33

2 out of 2 points

Select all of the following associated with Coronary Artery Disease.Answer

Selected Answers:

increased cholesterol levels

high fat diet

atherosclerotic plaques in coronary (heart) blood vessels

Correct Answers:

increased cholesterol levels

high fat diet

atherosclerotic plaques in coronary (heart) blood vessels

Question 34

2 out of 2 points


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Aplastic anemia is a disease in which the patient has peripheral blood

pancytopenial (decrease of al blood cell types due to problems with production inthe bone marrow.) Select all of the following that are clinical manifestations of

aplastic anemia.

Answer

Selected Answers:infection related to decreased WBCs

low hemoglobin related to decreased RBC production

bruising, easy bleeding related to decreased platelets

Correct Answers:infection related to decreased WBCs

low hemoglobin related to decreased RBC production

bruising, easy bleeding related to decreased platelets

Question 35

2 out of 2 points

Match the cardiac diagnostic test with the description.Answer


exercise stress test B.

used to evaluate the effect

of exercise on the heart

B.

used to evaluate the effect

of exercise on the heartechocardiogram C.

used to evaluation valve

function, and ejection

fraction ( how much bloodejected with each beat) of

the heart

C.used to evaluation valve

function, and ejection

fraction ( how much bloodejected with each beat) of

the heart


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MUGA test -

multigated

acquisition scan

A.

radioactive dye study used

to evaluate heart functionand valve function

A.

radioactive dye study used

to evaluate heart functionand valve function

angiography D.injected IV contrast

medium to obtain images ofblood vessels and diagnose


D.injected IV contrast

medium to obtain images ofblood vessels and diagnose


Question 36

0 out of 2 points

Select all that are true related to iron deficiency anemia.Answer

Selected

Answers: results from deficiency in diet or extensive bleeding

give liquid undiluted iron with a straw to avoid staining teeth

glossitis (inflammation of the tongue) and chelitis (inflammation

of the lips)

pallor

Correct

Answers:

results from deficiency in diet or extensive bleeding

give liquid undiluted iron with a straw to avoid staining teeth

give oral supplements of iron with a vitamin C source

glossitis (inflammation of the tongue) and chelitis (inflammation

of the lips)


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pallor

Question 37

2 out of 2 points

Select the following that are acceptable outcomes for a client with a nursing

diagnosis Risk for Aspiration. (Outcomes, not interventions)

Answer

Selected Answers:breath sounds are clear

Correct Answers:breath sounds are clear

Question 38

2 out of 2 points

In assessing the cardiac system, which of the following would indicate a problem ?Answer

SelectedAnswers: patient's heart rate is 120

patient is unable to perform activities of daily living because of

fatigue

patient's hands and feet are cold from lack of circulation

pt complains of chest pain that radiates to the jaw and left arm

patient has BP of 90/50

patient has leg and ankle edema


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Correct Answers:

patient's heart rate is 120

patient is unable to perform activities of daily living because offatigue

patient's hands and feet are cold from lack of circulation

pt complains of chest pain that radiates to the jaw and left arm

patient has BP of 90/50

patient has leg and ankle edema

Question 39

2 out of 2 points

In assessing the respiratory system, which of the following would indicate that the

person has a problem in the respiratory system?Answer

Selected

Answers: oxygen saturation of 86%

coughing up green secretions

abnormal breath sounds

can't speak more than 3 or 4 words without having to take a

breath in

Correct Answers:

oxygen saturation of 86%


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coughing up green secretions

abnormal breath sounds

can't speak more than 3 or 4 words without having to take a

breath in

Question 40

2 out of 2 points

Select all that are appropriate outcomes for a client with nursing diagnosis ofInfection.

Answer

Selected Answers:

clear yellow urine

WBC 5-10,000

T < 99 F

Correct Answers:

clear yellow urine

WBC 5-10,000

T < 99 F

Question 41

2 out of 2 points


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A 38 year old female refuses to look at her dressing after having a mastectomy for

breast cancer. She refuses to discuss the procedure and will not go out of the house.

She wears blouses that are three sizes too big. Select the appropriate nursingdiagnosis.

Answer

Selected Answer:Disturbed body image

Correct Answer:

Disturbed body image

Question 42

2 out of 2 points

Outcomes are expectations to be generated from the care given. Another term that

can be used is goals. Outcomes are the exact opposite of the assessment findingindicating the need for care. Select all of the following that would be accepted

goals for a client with a nursing diagnosis: Activity intolerance related to

generalized weakness.

Answer

Selected

Answers: abiltity to perform activities of daily living without exertional

dyspnea and significant change in vital signs; chest pain, diaphoresis,

or dizziness

verbalization of feeling less fatigued

hemoglobin/hematocrit 12/39

Correct

Answers:

abiltity to perform activities of daily living without exertionaldyspnea and significant change in vital signs; chest pain, diaphoresis,

or dizziness

verbalization of feeling less fatigued

hemoglobin/hematocrit 12/39


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Question 43

2 out of 2 points

In assessing diagnostic labs and procedures, which of the following would indicate

a problem in the problem that the nurse would include on a problem list.Answer

Selected Answers:

glucose 50

hemoglobin 8

chest x-ray showing infiltrates in the lungs

electrocardiogram (EKG) showing a HR of 125

Correct Answers:glucose 50

hemoglobin 8

chest x-ray showing infiltrates in the lungs

electrocardiogram (EKG) showing a HR of 125

Question 44

2 out of 2 points

In assessing the Gastrointestinal system, which of the following would indicate a

problem?Answer

Selected Answers:

constipation


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pain in the right upper quadrant

blood in the stools

diarrhea

vomiting blood

abdominal distention

Correct Answers:

constipation

pain in the right upper quadrant

blood in the stools

diarrhea

vomiting blood

abdominal distention

Question 45

2 out of 2 points

Ineffective tissue perfusion results from a decrease in oxygen due to lack of

perfusion (decreased blood flow) resulting in failure to nourish the tissues at thecapillary level. Select all of the following that are desired outcomes for a client

with Ineffective tissue perfusion (outcomes, not interventions)

Answer

Selected Answers:


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BP within normal range

urine output > 30 ml/hr

capillary refil < 3 seconds

extremities warm with absence of pallor and cyanosis

Correct Answers:BP within normal range

urine output > 30 ml/hr

capillary refil < 3 seconds

extremities warm with absence of pallor and cyanosis

Question 46

2 out of 2 points

A patient was admitted after going on a drinking binge. He has a history of

dysphagia (difficulty swallowing), and a depressed gag reflex.Answer

Selected Answer:

Risk for aspiration

Correct Answer:

Risk for aspiration

Question 47

2 out of 2 points

Patient has BP 90/50, dry oral mucous membranes, has lost 3 pounds in 2 days; hasnot been able to keep anything down, has capillary refil > 3 seconds. Select the


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appropriate nursing diagnosis.

Answer

Selected Answer:Fluid volume deficit

Correct Answer:Fluid volume deficit

Question 48

2 out of 2 points

In assessing the immune system, which of the following would indicate that the

person has an infection?Answer

Selected

Answers: cloudy urine

redness, pain, and yellow drainage from a wound

swollen, tender lymph nodes

increased erythrocyte sedimentation rate (ESR) - taking a longer

period of time for red blood cells to settle down in a test tube

WBCs in the urine

temperature of 101 F

Correct

Answers:

cloudy urine

redness, pain, and yellow drainage from a wound

swollen, tender lymph nodes


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increased erythrocyte sedimentation rate (ESR) - taking a longer

period of time for red blood cells to settle down in a test tube

WBCs in the urine

temperature of 101 F

Question 49

2 out of 2 points

Patient complains of fatigue; is unable to put clothes on without stopping for rest;

heart rate increases with activity. Select the approprite nursing diagnosis.Answer

Selected Answer:Activity intolerance

Correct Answer:

Activity intolerance

Question 50

2 out of 2 points

Which of the following are anticipated outcomes for a nursing diagnosis of

Impaired Gas exchange? (outcomes, not interventons)Answer

Selected Answers:

pulse oximetery > 94%

RR 12-20

patient is alert and oriented x 3

apply oxygen to maintain pulse ox > 94%

Correct Answers:


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pulse oximetery > 94%

RR 12-20

patient is alert and oriented x 3

apply oxygen to maintain pulse ox > 94%

Sunday, April 22, 2012 5:02:22 PM EDT

Aha Exam 2 Revised

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