RELIAS MEDICAL SURGICAL TELEMETRY ACTUAL EXAM 2024 TEST BANK COMPLETE 180 QUESTIONS AND CO, Exams of Nursing

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RELIAS MEDICAL SURGICAL TELEMETRY

ACTUAL EXAM 2024 TEST BANK COMPLETE 180

QUESTIONS ANDCORRECT DETAILED ANSWERS

WITH

RATIONALES (VERIFIED ANSWERS) |ALREADY

GRADED A+ Chamberlain College of Nursing |

Your inserting a urinary catheter into a male client. As you inflate a balloon, the client complains of discomfort what is the best action? - CORRECT--Aspirate the fluid, advance the catheter farther, then re-inflate the balloon When assessing a client, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - CORRECT--Subcutaneous emphysema Your client 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 client. What is your recommendation? - CORRECT--Request an order for soft mitts as they are the least restrictive Your client 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--Ask the client when his last drink of alcohol was. You are providing client education to a client prior to

administering IV Protonix.... When there is no history of GERD

CORRECT--Protonix is given as G.I. prophylaxis to prevent stress ulcers The client has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O saturation of 82%. What medication would be given in the situation? - CORRECT--Narcan Your client is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT? - CORRECT--Perform a bladder scan A client with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - CORRECT--Severe abdominal pain or rebound tenderness What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - CORRECT--Level of consciousness In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - CORRECT--Paresthesia and paralysis You received a report on a client that sustained a right hemisphere CVA 48 hours ago. What do you expect the client to exhibit? - CORRECT--Left sided weakness of the leg, arm, and face. You are ordered to give digoxin (Lanoxin). Your clients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT? - CORRECT--Hold

digoxin (Lanoxin) and call the provider

You were caring for a client who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The client may be experiencing: - CORRECT--Pulmonary embolism Cardiac strip - CORRECT--Unable to determine At 0500, you know your client to be diaphoretic, clammy, and their hands are shaking. The client's blood sugar is currently 60. Which of the following is the most appropriate intervention

• CORRECT--Have the client drink 120 ML's of orange juice
  • CORRECT--Ventricular tachycardia
  • CORRECT--Normal sinus rhythm Which of the following food items would you question in the menu of your client who is diagnosed with celiac disease? - CORRECT--Wheat bread A postoperative laparoscopic appendectomy client is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - CORRECT--A respiratory rate of 8 breaths per minute
  • CORRECT--Paced rhythm Your client was admitted with severe dehydration. Which of the following orders would you question - CORRECT--KCI 40 mEq IV push STAT What is the first sign of increased intracranial pressure? - CORRECT--Change in LOC

A client suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - CORRECT--Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin The Glasgow, scale ranges from: - CORRECT-- 3 to 15 You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a client who has C-Diff. What education should you provide to the nurse aide - CORRECT--And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff Heart rate - CORRECT-- 80 Which of the following assessment findings should you report immediately to the physician for a client who just had a bronchoscopy and biopsy? - CORRECT--Sputum with streaks of blood NOT: increased salivation Your client was just returned from surgery with a Jackson- Pratt JP drain in place which of the following is the best nursing action? - CORRECT--Compress the drain, then plug the bulb to establish suction Client is admitted for shortness of breath. Do you notice the spouse adjusting the oxygen on the wall and she states "she always takes care of my husband" what would be an appropriate response? - CORRECT--Educate the spouse on oxygen use as a medical device in the hospital Deposition has ordered for your patience to begin a 24 hour urine collection. Your client voids for the first time two hours

after the orders received. What should be done with this urine

sample? - CORRECT--Discarded, then begin the 24 hour collection Which of the following lab values would you expect to see in a client diagnosed with?.... - CORRECT--Lipase - 196 You were caring for a client admitted with abdominal pain. Your client has a bowel movement and you know dark tarry stool what would be the diagnosis? - CORRECT--Upper G.I. bleed Your COPD client is complaining of wheezing and increased shortness of breath - CORRECT--Assess your client for a change in condition What information is vital for you to know prior to administering an ordered dose of digoxin - CORRECT--Heart rate Your client has been diagnosed with a hemorrhagic CVA - CORRECT--Heparin infusion per pharmacy protocol A 56 - year-old man has an acute onset of shortness of breath, chest pain, apprehension, rapid pulse, cough with bloody sputum, diaphoresis, and syncope. The symptoms are indicative of: - CORRECT--Pulmonary embolism? NOT: tuberculosis You're reviewing the menu list of a client on Warfran what food should they not eat? - CORRECT--Spinach Which of the following issues should be reported up the chain of command - CORRECT--A coworker arriving to work under the influence of alcohol

You're providing discharge instructions to a CHF client. - CORRECT--Increase shortness of breath

cardiac rhythm - CORRECT--V-Tach Which of the following electrolyte value should be Addressed immediately by the nurse - CORRECT--Potassium 2.5 mEq/L Which of the following medication may cause urine discoloration - CORRECT--Rifampin Calculate the 12 hour intake for a client that has received the following during your shift: normal saline 750 ML, 24 ounces of sprite, Levaquin 50 ML, 650 ML urine in Foley catheter - CORRECT-- 1520 When caring for a client experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - CORRECT--Protecting the client's head and extremities from contact with surrounding objects You went to the room of a 58 - year-old female. You find that the client's cardiac monitor shows asystolye, what should be your first action? - CORRECT--Assess the client Not: start CPR Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - CORRECT--Women could have pain in their arm, neck, back or jaw While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness - CORRECT--Refused to sign for the waste Cardiac strip - CORRECT--Sinus rhythm with PAC

You're preparing your client for discharge need to provide dietary education related to his diagnosis what should you instruct the client to avoid? - CORRECT--Canned meats Your client complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - CORRECT--Perform a bladder scan The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - CORRECT--4ml After a client completes dialysis, you should anticipate seeing an improvement in which of the following lab values? - CORRECT--NOT: ammonia Your client fell and hit his head on the bed rail during a physical therapy session. Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. The client is lying in a supine position. What should be your first response? - CORRECT--Call a rapid response Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - CORRECT--Metformin You're a king for a client who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced - CORRECT--Apply sterile saline soap towels over the extruding site One of the signs of left sided heart failure is: - CORRECT--Pulmonary edema NOT: pedal edema Your client had a TB skin test done on Thursday at 2:45 PM -

CORRECT--Saturday at 3 PM

1.2 milligrams is equal to how many micrograms? - CORRECT-- 1200 mcg What lab values are expected to be in a client with end stage renal disease on hemodialysis - CORRECT--BUN 32, CREATNINE 8. dietary teaching for a client with chronic renal failure should include choices that are: - CORRECT--Low potassium, low protein, moderate fat Your post-op client has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function? - CORRECT--Compress the drain, then plug the bulb to establish suction Your male client complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action? - CORRECT--Deflate the balloon, advance the catheter further, then reinflate the balloon What are the most common causes of acute onset pancreatitis? - CORRECT--Alcoholism and gallstones What medication is contraindicated In a client with A hemorrhagic CVA? - CORRECT--heparin Your client appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? - CORRECT--Initiate a code per facility protocol and begin CPR A client with diabetes who is receiving peritoneal dialysis Is at risk for which of the following? - CORRECT--hyperglycemia

Your client has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? - CORRECT--Respect his wishes and notify the provider Your client is admitted with diverticulitis. What type of diet do you expect to be ordered for the client? - CORRECT--broth, jello, soft fruit no skin, clear liquids You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post- surgical unit since they are understaffed. Which is the MOST appropriate action? - CORRECT--Report to the post-surgical unit. You are to obtain informed consent for a Spanish-speaking client scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your client. Which of the following resources would be most appropriate to utilize in order to obtain consent? - CORRECT--The hospitals language interpreter You're reviewing the discharge medication list of a client diagnosed with gastric ulcer. Which of the following medication should you question? - CORRECT--Acetylsalicylic acid ( Bauer buffered aspirin) When taking care of a client with pancreatitis, which of the following lab should be reviewed? - CORRECT--Lipase and amylase You're caring for a 12 hour postoperative parathyroidectomy client. Which assessment finding would indicate an emergency? - CORRECT--Laryngeal strider

Which of the following actions would be considered a violation of Hyppa? - CORRECT--Looking through the chart of a coworker admitted to your unit

• CORRECT--Sinus tachycardia You are taking care of a client who is admitted for left flank pain with a kidney stone of 1.5 cm. He asks you about the procedure what would be the most therapeutic response? - CORRECT--Due to the size of the kidney stone it is an appropriate treatment? NOT:Print reading materials about the subject and give it to the client The nurse is taking care of a client who is terminally ill and has a DNR on file. Their client has a sudden cardiac arrest and family wants CPR initiated. How should you respond? - CORRECT--Honor the client's wishes
• CORRECT--Not normal sinus rhythm into a flutter Correct answer is ventricular fibrillation What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - CORRECT--Acid Reduction Which adaptive equipment would be MOST appropriate to use for a severely contracted client who is unable to bear weight when transferring from the bed to the chair? - CORRECT--Client lift (e.g., Hoyer) Which tool should you use to assess pain in you 80 - year- old client with severe dementia? - CORRECT--PAINAD scale

Your 85 - year-old client 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--Hold wayfaring (coumadin) for the next 48 hours Stat CT of head Your client 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--Notify the charge nurse and social worker of your concerns. Your client 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 client MOST likely experiencing. - CORRECT--Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a client with C. diff? - CORRECT--Gown and gloves What is the BEST indication of an acute neurological problem?

• CORRECT--Change in level of consciousness While in a supine position your client 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--Heart failure

Your client began deteriorating rapidly after complaining of shortness of breath. And ABG was drawn and the results are

pH? HCO3 - 23. These values indicate the client is experiencing: - CORRECT-- 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--Airborne precautions Clients with diabetes are at high risk for complications from damage to what body areas? - CORRECT--Nerve and kidney damage If your client with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action? - CORRECT--Check the client's blood glucose level. Your client 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--Discuss code status with the client 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--No action is necessary because no PHI was displayed. Your new client understands very limited English. How should you communicate with them when completing the admission assessment? - CORRECT--Use the organization's interpreter services.

You are caring for a client with a history of diabetes mellitus. You walk into the room and find the client lethargic and diaphoretic. What is your first action? - CORRECT--Obtain capillary blood glucose level. Upon entry to your client's room, you find her sitting in High Fowler's position and complaining of shortness of breath. Her respiratory rate is 34 breaths/min and O2 sat is 84%. Which mode of oxygen delivery would MOST likely reverse these symptoms? - CORRECT--Non-rebreather mask Your client is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - CORRECT--Gown and gloves Your client recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings? - CORRECT--Vomiting and diarrhea Upon entering your client's room, you note that they are having a seizure. What is your FIRST action? - CORRECT--Position the client on their side to maintain the airway. Your 18 - year-old female client 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--Stay with the client and ask fi she has a plan to carry out this wish. Your client has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the client,

what should you do FIRST? - CORRECT--Hyperoxygenate client. Your client takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect? - CORRECT--Gastrointestinal bleeding Your new client 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--Hemorrhage Which of the following nursing diagnoses is MOST important for a client with chronic obstructive pulmonary disease (COPD)? - CORRECT--Impaired gas exchange You have a client 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--famotidine (Pepcid) What is an early symptom that the client is developing a complication of heart failure? - CORRECT--Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? - CORRECT--Bleeding gastric ulcer You have 4 clients 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 client should you tend to FIRST? - CORRECT--

The client with chest pain

Your client 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 client? - CORRECT--Paracentesis What is clubbing of the fingers MOST likely associated with? - CORRECT--Chronic oxygen deficiency A client on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? - CORRECT--Vitamin K To reduce the risk of infection and phlebitis in an adult client with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE replacement?

• CORRECT-- 72 hours You are caring for a client post lobectomy with a chest tube in place for drainage. What is a priority in care for this client?
• CORRECT--Encourage the client to cough and deep breathe. What client population is the pneumococcal vaccine, PPSV23 indicated for? - CORRECT--Adults aged 65 years and older Your client with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this client? - CORRECT--Palliative care consult The provider gives you a telephone order to explain a surgical procedure to your client and obtain surgical consent. How should you respond? - CORRECT--Inform the provider

that explaining the procedure is outside the nurse's scope of practice.

The client has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond? - CORRECT--"Sorry, it is a slow- release medication that cannot be opened or crushed." Which adaptive equipment would be most appropriate to use for a severely contracted client who is unable to bear weight when transferring from bed to chair - ...ANSWER..Client Lift example hoyer What lab values are expected to be in a client with end stage renal disease on hemodialysis - ...ANSWER..BUN 32, CREATNINE 8.32 Your 85 year old client 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? You're? - ...ANSWER..Hold wayfaring (coumadin) for the next 48 hours Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? - ...ANSWER..Airborne precautions Upon entering your client's room you note that they are having a seizure. What is your 1st action? - ...ANSWER..Position the client on their side to maintain the airway You find your coworker looking through your client's medical record.. She States how is Mr. Smith doing? He is my best friend's dad. We are so worried about him. What is the best

course of action? - ...ANSWER..Tell her you cannot give her information and report her actions to your manager.