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

Download RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK COMPLETE 180 QUESTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity! RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK COMPLETE 180 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ...ANSWER...Aspirate the fluid, advance the catheter farther, then re-inflate the balloon When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - ...ANSWER...Subcutaneous emphysema 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? - ...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? - ...ANSWER...Ask the patient when his last drink of alcohol was. You are providing patient education to a patient prior to administering IV Protonix.... When there is no history of GERD - ...ANSWER...Protonix is given as G.I. prophylaxis to prevent stress ulcers The patient has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O2 saturation of 82%. What medication would be given in the situation? - ...ANSWER...Narcan Your patient is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT? - ...ANSWER...Perform a bladder scan A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - ...ANSWER...Severe abdominal pain or rebound tenderness What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - ...ANSWER...Level of consciousness In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - ...ANSWER...Paresthesia and paralysis You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? - ...ANSWER...Left sided weakness of the leg, arm, and face. You are ordered to give digoxin (Lanoxin). Your patients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT? - ...ANSWER...Hold digoxin (Lanoxin) and call the provider sample? - ...ANSWER...Discarded, then begin the 24 hour collection Which of the following lab values would you expect to see in a patient diagnosed with?.... - ...ANSWER...Lipase - 196 You were caring for a patient admitted with abdominal pain. Your patient has a bowel movement and you know dark tarry stool what would be the diagnosis? - ...ANSWER...Upper G.I. bleed Your COPD patient is complaining of wheezing and increased shortness of breath - ...ANSWER...Assess your patient for a change in condition What information is vital for you to know prior to administering an ordered dose of digoxin - ...ANSWER...Heart rate Your patient has been diagnosed with a hemorrhagic CVA - ...ANSWER...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: - ...ANSWER...Pulmonary embolism? NOT: tuberculosis You're reviewing the menu list of a patient on Warfran what food should they not eat? - ...ANSWER...Spinach Which of the following issues should be reported up the chain of command - ...ANSWER...A coworker arriving to work under the influence of alcohol You're providing discharge instructions to a CHF patient. - ...ANSWER...Increase shortness of breath cardiac rhythm - ...ANSWER...V-Tach Which of the following electrolyte value should be Addressed immediately by the nurse - ...ANSWER...Potassium 2.5 mEq/L Which of the following medication may cause urine discoloration - ...ANSWER...Rifampin Calculate the 12 hour intake for a patient 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 - ...ANSWER...1520 When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - ...ANSWER...Protecting the patient's head and extremities from contact with surrounding objects You went to the room of a 58-year-old female. You find that the patient's cardiac monitor shows asystolye, what should be your first action? - ...ANSWER...Assess the patient Not: start CPR Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ...ANSWER...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 - ...ANSWER...Refused to sign for the waste Cardiac strip - ...ANSWER...Sinus rhythm with PAC You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ...ANSWER...Canned meats Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ...ANSWER...Perform a bladder scan The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ...ANSWER...4ml After a patient completes dialysis, you should anticipate seeing an improvement in which of the following lab values? - ...ANSWER...NOT: ammonia Your patient 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 patient is lying in a supine position. What should be your first response? - ...ANSWER...Call a rapid response Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - ...ANSWER...Metformin You're a king for a patient who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced - ...ANSWER...Apply sterile saline soap towels over the extruding site One of the signs of left sided heart failure is: - ...ANSWER...Pulmonary edema NOT: pedal edema Your patient had a TB skin test done on Thursday at 2:45 PM - ...ANSWER...Saturday at 3 PM Which of the following actions would be considered a violation of Hyppa? - ...ANSWER...Looking through the chart of a coworker admitted to your unit - ...ANSWER...Sinus tachycardia You are taking care of a patient 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? - ...ANSWER...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 patient The nurse is taking care of a patient who is terminally ill and has a DNR on file. Their patient has a sudden cardiac arrest and family wants CPR initiated. How should you respond? - ...ANSWER...Honor the patient's wishes - ...ANSWER...Not normal sinus rhythm into a flutter Correct answer is ventricular fibrillation What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - ...ANSWER...Acid Reduction Which adaptive equipment would be MOST appropriate to use for a severely contracted patient who is unable to bear weight when transferring from the bed to the chair? - ...ANSWER...Patient lift (e.g., Hoyer) Which tool should you use to assess pain in you 80-year-old patient with severe dementia? - ...ANSWER...PAINAD scale 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? - ...ANSWER...Hold wayfaring (coumadin) for the next 48 hours Stat CT of head 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? - ...ANSWER...Notify the charge nurse and social worker of your concerns. 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. - ...ANSWER...Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? - ...ANSWER...Gown and gloves What is the BEST indication of an acute neurological problem? - ...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? - ...ANSWER...Heart failure Your patient began deteriorating rapidly after complaining of shortness of breath. And ABG was drawn and the results are pH? HCO3 - 23. These values indicate the patient is experiencing: - ...ANSWER... 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? - ...ANSWER...Airborne precautions Patients with diabetes are at high risk for complications from damage to what body areas? - ...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? - ...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? - ...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? - ...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? - ...ANSWER...Use the organization's interpreter services. 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? - ...ANSWER...Paracentesis What is clubbing of the fingers MOST likely associated with? - ...ANSWER...Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? - ...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? - ...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? - ...ANSWER...Encourage the patient to cough and deep breathe. What patient population is the pneumococcal vaccine, PPSV23 indicated for? - ...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? - ...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? - ...ANSWER...Inform the provider that explaining the procedure is outside the nurse's scope of practice. The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond? - ...ANSWER..."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 patient who is unable to bear weight when transferring from bed to chair - ...ANSWER..Patient Lift example hoyer What lab values are expected to be in a patient with end stage renal disease on hemodialysis - ...ANSWER..BUN 32, CREATNINE 8.32 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? 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 patient's room you note that they are having a seizure. What is your 1st action? - ...ANSWER..Position the patient on their side to maintain the airway You find your coworker looking through your patient'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. Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling urinary catheter. What would be the most appropriate action? - ...ANSWER..Deflate the balloon, advance the catheter further, then reinflate the balloon. Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the patient be taught to be alert for signs of hypoglycemia? - ...ANSWER..Is late afternoon and early morning What is a proton pump inhibitor, such as pantoprazole (protonix) used for? - ...ANSWER..Reduce gastric acid secretion Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to sectioning the patient, what should you do 1st? - ...ANSWER..Hyperoxygenate patient dietary teaching for a patient with chronic renal failure should include choices that are: - ...ANSWER..Low potassium, low protein, moderate fat Which of the following nursing diagnosis is most important for a patient with chronic obstructive pulmonary disease(COPD) - ...ANSWER..Impaired gas exchange 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? - ...ANSWER..Notify the charge nurse and social worker of your concerns. assessment that the stomach is rigid and hard during palpation. What condition do you suspect. - ...ANSWER..Hemorrhage What is clubbing of the fingers most likely associated with? - ...ANSWER..Chronic oxygen deficiency Is 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? - ...ANSWER..Paracentesis Is the provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? - ...ANSWER..Inform the provider that explaining the procedure is outside the nurse's scope of practice. You're patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What symptoms may indicate intolerance to the feedings? - ...ANSWER..Vomiting and diarrhea You are caring for a patient post lobotomy With a chest tube in place for drainage. What is a priority in caring for this patient? - ...ANSWER..Encourage the patient to cough and deep breathe. Your new patient understands very limited English. How should you communicate with them when completing the admission assessment? - ...ANSWER..Use the organizations interpreter services You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR 16, o2 sat 100% on room air. What should you do next? - ...ANSWER..HOLD DIGOXIN AND CALL PROVIDER 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? - ...ANSWER..Discuss code status with the patient and follow up with the provider to ensure the medical record reflects her wishes What are the most common causes of acute onset pancreatitis? - ...ANSWER..Alcoholism and gallstones Your 18 year old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat effect and says" I just want to die, I'm tired of my life ". What should be your 1st intervention? - ...ANSWER..Stay with the patient and ask if she has a plan to carry out this wish A patient with diabetes who is receiving peritoneal dialysis Is at risk for which of the following? - ...ANSWER..? To reduce the risk of infection and phlebotomy in an adult patient with a peripherL IV, What is the minimum duration the catheter should remain in place before routine replacement. - ...ANSWER..72 hours Your patient was admitted for a hypertensive crisis and has a history of HTN. Parkinson disease, depression and alcohol use. On his 2nd hospitalized day, you notice he is more anxious and restless than his baseline. What would be your 1st nursing intervention? - ...ANSWER..Ask the patient when his last drink of alcohol was Black and tarry Colored stools are classic symptoms of what condition? - ...ANSWER..Bleeding gastric ulcer In addition to pain, pallor, and pulselssness, a neurovascular assessment Also includes checking for - ...ANSWER..Parasthesia and paralysis After scrolling through your social media, you notice a coworker posted a photo with a patient from your unit. What is the most appropriate action to take? - ...ANSWER..Report the situation to the hospital compliance officer. Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer? - ...ANSWER..PRBCs What medication is contraindicated In a patient with A hemorrhagic CVA? - ...ANSWER..Heparin Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? - ...ANSWER..Initiate a code per facility protocol and begin CPR Your 68 year old patient is a is a Type one diabetic with a history of schizophrenia And exhibit signs and symptoms of tardiness dyskinesia. Is what long term medication is associated with signs and symptoms of tardive dyskinesia? - ...ANSWER..Chlorpromazine(thorazine) You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? - ...ANSWER..Lift sided weakness of the leg, arm, and face and face You have 4 patients who have high priority needs. One needs to go to surgery, 1 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 1st? - ...ANSWER..The patient with chest pain