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NUR-265 Exam 1 Newest 2025 Includes Accurate And Verified Questions Covering Critical Care Nursing Topics Such As Cardiovascular And Respiratory Disorders, Fluid And Electrolyte Balance, Acid-Base Imbalances, Pharmacology, And Nursing Interventions For Acutely Ill Patients. Designed For Nursing Students Beginning Advanced Medical-Surgical Coursework.
An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding would the nurse report to the health care provider?
- Tympany on percussion of the abdomen
- Liver edge 3 cm below the costal margin
- Bowel sounds of 20/min in each quadrant
- Aortic pulsations visible in the epigastric area
ANS: B
Rationale; Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight.
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A patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by assistive personnel (AP) requires that the registered nurse (RN) intervene?
- Offering the patient a pitcher of water
- Positioning the patient on the right side
- Checking the vital signs every 30 minutes
- Swabbing the patient's mouth with a wet cloth
ANS: A
Rationale; Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the AP are appropriate.
A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action would the nurse take first?
- Place the patient on NPO status.
- Administer sedative medications.
- Ensure the consent form is signed. 2 / 4
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- Teach the patient about the procedure.
ANS: A
Rationale; The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). Which area of patient knowledge would the nurse plan to assess?
- Preventing noninfectious hepatitis
- Treating inflammatory bowel disease
- Risk for developing colorectal cancer
- Using antacids and proton pump inhibitors
ANS: C
Rationale; FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.
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Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation?
- Glossitis
- Ecchymoses
- Dry, scaly skin
- Gingival swelling
ANS: A
Rationale; Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as glossitis, anorexia, sore mouth and tongue, pallor, neurologic problems (e.g., depression, dizziness), weight loss, nausea, constipation, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.
A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted. Which assessment finding would the nurse expect?
- Restlessness
- Hypertension
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