NUR 2115 Exam 2 NUR 211 Exam 2 Fundamentals of

NUR 2115 Exam 2 / NUR 211 Exam 2 Fundamentals of Nursing

• The most appropriate nursing order for a patient who develops

dyspnea and shortness of breath would be…

• Maintain the patient on strict bed rest at all times
• Maintain the patient in an orthopneic position as needed
• Administer oxygen by Venturi mask at 24%, as needed
• Allow a 1 hour rest period between activities

• When a patient develops dyspnea and shortness of breath, the orthopneic

position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia.

• The nurse observes that Mr. Adams begins to have increased difficulty

breathing. She elevates the head of the bed to the high Fowler position, which

decreases his respiratory distress. The nurse documents this breathing as:

• Tachypnea
• Eupnca
• Orthopnea
• Hyperventilation

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C . Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort.

• The physician orders a platelet count to be performed on Mrs. Smith after

breakfast. The nurse is responsible for:

• Instructing the patient about this diagnostic test
• Writing the order for this test
• Giving the patient breakfast
• All of the above

C . A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test.

• Mrs. Mitchell has been given a copy of her diet. The nurse discusses the

foods allowed on a 500-mg low sodium diet. These include:

• A ham and Swiss cheese sandwich on whole wheat bread
• Mashed potatoes and broiled chicken
• A tossed salad with oil and vinegar and olives
• Chicken bouillon

• Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham,

olives, and chicken bouillon contain 2 / 3

large amounts of sodium and are contraindicated on a low sodium diet.

• The physician orders a maintenance dose of 5,000 units of subcutaneous

heparin (an anticoagulant) daily.

Nursing responsibilities for Mrs. Mitchell now include:

• Reviewing daily activated partial thromboplastin time (APTT) and prothrombin

time.

• Reporting an APTT above 45 seconds to the physician
• Assessing the patient for signs and symptoms of frank and occult bleeding
• All of the above

D . All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.

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