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NR 341 FINAL Exam

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NR 341 FINAL Exam A hospice nurse who has become close to a terminally ill patient is presented in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? Cry along with the patient's family members The son of a dying patient tells the nurse, "Mother doesn't respond any more when I visit, I don't think she knows that I am here". Which response by the nurse is appropriate? "Withdrawal can be a normal response in the process of dying." A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, paO2 32 mmHG, and HCO3 25 mEq/L? Respiratory Alkalosis An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? Na 154 mEq/L (154 mmo/L) A patient undergoing an emergency appendectomy has been using St. Johns wart to prevent depression. Which complication should the nurse expect in the post anesthesia care unit? Increased anesthesia recovery time A patient who takes a diuretic and a B-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? Serum potassium 3.2 mEq/L While in the holding area, a patient revels to the nurse that his father had a high fever immediately after surgery. What action by the nurse is a priority? Alert the anesthesia care provider of the family member's reaction to surgery. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. Which in the post anesthesia care unit (PACU). What assessment finding is most important for the nurse to report? Weak chest movement A patient who has begun to awaken after 30 minutes in the post anesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? Assess for bladder distension A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? Check the oxygen (O2) saturation On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 d/L), Serum K+ 4.9 mEq/L (4.8 mmol/L and serum Na+ 1345 mEq/L (135 mmo/L). Which of the following prescribed actions should be the nurse's priority? Increasing the rate of the ordered IV solution A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hrs. Is 30,000 mL. The initial rate of administration is 1875, L/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? 938 mL/hr. A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which actions should the nurse take first? Auscultate for breath sounds Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? Stabilize the cervical spine

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