Which patient statement should alert the nurse to

This preview shows page 23 - 27 out of 27 pages.

48. Which patient statement should alert the nurse to assess a bed-bound patient for indications of immobility-induced thrombophlebitis? 1) "One of my calves looks swollen." 2) "I have tingling sensations in my feet." 3) "The skin on my legs is extremely dry." 4) "The toes on my left foot feel cool when I touch them." A slowed blood flow and increased viscosity of the blood allow platelets and calcium to settle out against the intimal lining of a vein, which can result in thrombus formation. The inflammatory process causes calf edema, pain, heat, and erythema
49. A patient is diagnosed as having coronary artery disease. Which should the nurse encourage the patient to do to help limit atherosclerosis?
23
University of San Francisco School of Nursing and Health Professions N 624 Fundamentals HESI Review
50. A patient is admitted to a hospital with the medical diagnosis of obstructive airway disease. The patient is experiencing dyspnea, using accessory muscles to breathe, and receiving oxygen at 2 liters per minute via nasal cannula. Identify the site where the nurse should place the stethoscope to assess bronchovesicular breath sounds. 24
University of San Francisco School of Nursing and Health Professions N 624 Fundamentals HESI Review 1) 1 2) 2 3) 3 4) 4 To hear bronchovesicular breath sounds, the nurse should place the stethoscope over the first and second intercostal spaces just to the right and left of the sternum on the anterior chest wall. Bronchovesicular breath sounds are medium-pitched sounds heard as air moves through the large airways of the bronchi; inspiratory and expiratory phases are equal in duration. 50. Feedback 1: When skin on the back of the hand of a middle-aged adult is grasped and then released, it will return to its normal appearance when released. However, when a middle-aged person is hypovolemic, skin returns to its normal appearance more slowly because of inadequate local tissue hydration. Feedback 2: When a patient is hypovolemic, the heart rate will increase, not decrease, in an attempt to maintain an effective cardiac output. Feedback 3: Flat neck veins are associated with hypovolemia because of the decrease in the volume of circulating blood. Feedback 4: When a patient is hypovolemic, there is a reduced volume of circulating blood and less pressure within the vessels, which are reflected in weak, thready peripheral pulses and flattened neck veins. 25
University of San Francisco School of Nursing and Health Professions N 624 Fundamentals HESI Review

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture