Question

29. A patient is admitted to the intensive care unit after coronary artery bypass surgery. Twelve hours after admission to the ICU, which of the following findings would need to be communicated to the care provider immediately? PT/INR of 7.0 375 ml amber urine over the past eight hours 4/10 sternal incision pain A serum potassium of 4.5 mEq/L a. b. c. d. 30. A patient with a history of CAD, and an MI one year ago is diagnosed with chronic heart failure. The nurse is preparing the patient for discharge. Which of the following statements made by the patient demonstrates an understanding of discharge teaching? "I will eat the same amount of green-leafy vegetable daily" b. "I will increase my daily intake of sodium" "I will weigh myself daily" d. "I will increase my fluid intake" a. c. 31. Admission vital signs for a brain-injured patient with suspected increased ICP are blood pressure of 128/68 mmHg, HR 110 beats/minute and respirations 26 breaths/minute. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? BP 154/68; HR 56 beats per min; RR12 breaths per min and irregular a. BP 134/72; HR 90 beats per min; RR 32 breaths per min and regular b. c. BP 148/78; HR 112 beats per min; RR 28 breaths per min and irregular d. BP 110/70, HR 120 beats per min; RR 30 breaths per min and regular 32. A patient with a history of Type II Diabetes is admitted with HR 86, SR, BP 132/68, RR 18, 02 Saturation 98 % on room air, and a blood glucose of 408, and a serum potassium of 4.4. The patient is ordered for a regular insulin drip, NS IV at 150 ml/hour, 20 mEq Potassium IV, and Morphine 2 mg IV. Which intervention should the nurse perform first? a. IV Insulin b. IV NS C. IV Potassium Adf d. IV Morphine 33. A patient with a history of Type I Diabetes Mellitus arrives to the Emergency department lethargic, VS T 98.2 F, HR 72, RR 36 and shallow, BP 102/56, 02 Sats 93 % on RA. AbG; pH to 7.27, CO2 42, HCO3 14, and blood glucose 345. Based on these findings the patient is likely experiencing Hyperglycemia b. Diabetic metabolic alkalosis a. Diabetic ketoacidosis C d. Hyperglycemic Hyperosmolar Non-ketotic Syndrome bbs nit Ae up n at bluo o pu res

Answer 1

29. The correct option is B - 375ml amber urine over the past eight hours should be informed to the physician immediately because 30ml is the normal output per hour so it should be around 240 ml .

30. The correct option is C - I will weight myself daily because in heart failure chances of accumulation of fluid is more and it could result in edema and increase in weight.

31. The correct option is A - BP -154/ 68mmhg ,HR -56 bpm ,RR - 12 bpm and irregular because it indicates severe increase in ICP and it's called cushions triad .

32. The correct option is A- IV insulin because as per the priority ( blood glucose - 408 mg/dl ) she needs insulin therapy first to manage her glucose levels and other complications .