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ACM POST TEST 100% VERIFIED ANSWERS 2024/2025 CORRECT
Typology: Exams
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A nurse in the telemetry unit observes a rhythm of an irregular heart rate of 120 bpm. Based on an interpretation of the rhythm, what is the priority action of the nurse? ASSESS THE PATIENT'S CAROTID PULSE AND LEVEL OF CONSCIOUSNESS A patient is admitted for a poisonous snake bite. The nurse observes that the patient has hematuria, hemoptysis, petechiae, and excessive bruising. These critical observations indicate to the nurse that the patient may be experiencing which hemorrhagic complication associated with snakebites? DISSEMINATED INTRAVASCULAR COAGULATION A patient is admitted for emergency surgery after an accident. In addition, the patient has a pustular rash related to secondary syphilis. What instructions does the nurse give to the unlicensed assistive personnel (UAP)? GLOVES SHOULD BE WORN AT ALL TIMES WHEN TOUCHING THE PATIENT A patient/client has been brought to the emergency department with multiple traumas after a motor vehicle accident. After the nurse stabilizes the patient, which of the following would the nurse perform? Select all that apply.
126/68, pulse 110, and respirations 26. One hour after admission the nurse notes the presence of the Cushing's triad when the patient's/client's vital signs are:
The male patient/client with a c-6 spinal cord injury (SCI) tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the home health nurse implement? DETERMINE WHEN THE PATIENT/CLIENT LAST URINATED. The new registered nurse is giving a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse. Select all that apply. · I WILL BE SURE TO COMPLETE THE RED BLOOD CELL TRANSFUSIONS WITHIN 6 HOURS OF REMOVAL FROM REFRIGERATION · I WILL USE LACTATED RINGERS' SOLUTION TO DILUTE THE BLOOD · I WILL MONITOR VITAL SIGNS EVERY SHIFT AFTER THE INFUSION IS COMPLETE A nurse is caring for a female patient/client who sustained a closed head injury 8 days ago in motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury? THE PATIENT/CLIENT COMPLAINS OF EXTREME THIRST AND HAS AN INCREASED URINE OUTPUT A nurse is teaching a patient about preventing HIV infection through sexual contact. Which statement made by the patient indicates effective teaching? MUTUALLY MONOGAMOUS SEX WITH A NON-INFECTED PARTNER WILL BEST PREVENT HIV INFECTION The nursing student is assisting in the care of a patient on mechanical ventilator. Which action by the student contributes to the prevention of ventilator assisted pneumonia? PERFORMS ORAL CARE EVERY 2 HOURS The patient/client with myocardial infarction has undergone electrocardiography (ECG). What changes in the ECG tracing would the nurse expect to see in this patient/client? · ST SEGMENT ELEVATION · T WAVE INVERSION · ABNORMAL Q WAVE
What is the rationale for administering tissue plasminogen activator (t-PA) within 4.5 hours of thrombotic stroke? TO CAUSE FIBRINOLYSIS OF THE CLOT Which patient/client would the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A PATIENT/CLIENT WITH A BLUNT CHEST TRAUMA & SOME DIFFICULTY BREATHING