Medical-Surgical RN A Prophecy Relias, Exams of Medicine

Download Medical-Surgical RN A Prophecy Relias and more Exams Medicine in PDF only on Docsity! Medical-Surgical RN A Prophecy Relias with Questions and Correct Answers Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely experiencing. Correct Answer Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? Correct Answer Gown and gloves Your patient continues to pull at their IV site located in their left forearm despite verbal reminders and increased observation. The nursing assistant recommends using soft mitt restraints on the patient. What is your recommendation? Correct Answer Request an order for soft mitts as they are the least restrictive Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson's disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST nursing intervention? Correct Answer Ask the patient when his last drink of alcohol was. What is the BEST indication of an acute neurological problem? Correct Answer Change in level of consciousness While in a supine position your patient states, "I'm tired and cannot catch my breath." Physical assessment reveals jugular vein distention and a third heart sound (S3). These symptoms are indicative of what condition? Correct Answer Heart failure Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? Correct Answer Airborne precautions Patients with diabetes are at high risk for complications from damage to what body areas? Correct Answer Nerve and kidney damage If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action? Correct Answer Check the patient's blood glucose level. Your patient tells you, "I hope I don't die, but if I do I don't want to be brought back.? You notice on her chart and wrist band that she is a full code. What would be the MOST appropriate action? Correct Answer Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes. Your coworker posted photos on social media from a birthday party they had for her in the unit breakroom. What should be your NEXT course of action? Correct Answer No action is necessary because no PHI was displayed. Your new patient understands very limited English. How should you communicate with them when completing the admission assessment? Correct Answer Use the organization's interpreter services. You are caring for a patient with a history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your first action? Correct Answer Obtain capillary blood glucose level. Which tool should you use to assess pain in you 80-year-old patient with severe dementia? Correct Answer PAINAD scale Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do? Correct Answer Notify the charge nurse and social worker of your concerns. Your 85-year-old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the MOST important order you should anticipate from the provider? Correct Answer Stat CT of head Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings? Correct Answer Vomiting and diarrhea Upon entering your patient's room, you note that they are having a seizure. What is your FIRST action? Correct Answer Position the patient on their side to maintain the airway. Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, "I just want to die. I'm tired of my life." What should be your FIRST intervention? Correct Answer Stay with the patient and ask fi she has a plan to carry out this wish. Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST? Correct Answer Hyperoxygenate patient. Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect? Correct Answer Gastrointestinal bleeding Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). A NG tube is in place for decompression; however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect? Correct Answer Hemorrhage Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)? Correct Answer Impaired gas exchange You have a patient going for dialysis. Their medications include lisinopril (Prinivil), ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication would you possibly hold and seek clarification? Correct Answer famotidine (Pepcid) What is an early symptom that the patient is developing a complication of heart failure? Correct Answer Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? Correct Answer Bleeding gastric ulcer You have 4 patients who have high priority needs. One needs to go to surgery, one needs STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs toileting. Which patient should you tend to FIRST? Correct Answer The patient with chest pain Your patient with Hepatitis C exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient? Correct Answer Paracentesis What is clubbing of the fingers MOST likely associated with? Correct Answer Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? Correct Answer Vitamin K To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE replacement? Correct Answer 72 hours You are caring for a patient post lobectomy with a chest tube in place for drainage. What is a priority in care for this patient? Correct Answer Encourage the patient to cough and deep breathe. What patient population is the pneumococcal vaccine, PPSV23 indicated for? Correct Answer Adults aged 65 years and older Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient? Correct Answer Palliative care consult The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? Correct Answer Inform the provider that explaining the procedure is outside the nurse's scope of practice. fluctuates throughout the day. His medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect? Correct Answer Delirium What is the proper technique when suctioning a tracheostomy? Correct Answer Suction in a circular motion while the catheter is being pulled out. Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the hospital for her surgery. What action is MOST appropriate for you to take? Correct Answer Sit calmly next to her and offer her compassion and a sense of security. The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How many mLs per hour should the IV pump be set to? Correct Answer 167 mL/hr You are assigned a new admission and note a Braden score of 11 after completing your assessment. Which interventions would be MOST appropriate based on your assessment? Correct Answer Turn q 2hours, request nutrition consult, request low airloss mattress. Your patient may have tuberculosis TB) and is placed in airborne precautions. What test would you expect to be ordered? Correct Answer Acid-fast bacilli sputum Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What diagnosis do you suspect? Correct Answer Congestive heart failure You received a patient post op transurethral resection of the prostate (TURP). Which of the following symptoms would cause you the MOST concern? Correct Answer Hemorrhage and hypotension Your patient with C. diff (Clostridioides difficile) has a family member about to leave the room. What education about performing hand hygiene should you give? Correct Answer Hand hygiene with soap and water Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following medications would cause this side effect? Correct Answer Phenazopyridine (Pyridium) Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient? Correct Answer Increase risk of digoxin toxicity You are preparing to hang 1 unit PRBC's to administer to your patient. The patient states, "I don't take blood products." What is the MOST appropriate response? Correct Answer "You have the right to refuse the blood transfusion. I will inform the provider of your decision." An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you suspect? Correct Answer Neglect You just left your patient's room with her husband at bedside. You then receive a phone call from someone states that she is your patient's mother and demands updates about your patient. What should you do NEXT? Correct Answer Verify your patient's consent to release information to her mother. The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many units should you administer? Correct Answer 320 units What diagnostic finding would support a diagnosis of deep vein thrombosis? Correct Answer Positive D-dimer You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and anemia. The family states he appears to be more confused than his baseline. What tests do you expect the provider to order? Correct Answer Urinalysis with cultures, CBC A patient has recently been diagnosed with terminal cancer. Her responses are caustic and abrasive. What is the BEST way to respond? Correct Answer Acknowledge her feelings, understanding this is expected in the grieving process. You notice your patient who recently had a stroke is coughing intermittently during meals. What is the MOST likely cause of this? Correct Answer He could be aspirating. A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what quadrant? Correct Answer Left lower quadrant Which of the following is MOST important in preventing a catheter associated urinary tract infection (CAUTI)? Correct Answer Using sterile technique when inserting the catheter