RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024/2025 TEST BANK COMPLETE 300 QUESTIONS AND CORR, Exams of Nursing

Download RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024/2025 TEST BANK COMPLETE 300 QUESTIONS AND CORR and more Exams Nursing in PDF only on Docsity! RELIAS MEDICAL SURGICAL 1 - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter Correct answer is ventricular fibrillation - ansPaced rhythm - ansSinus tachycardia - ansVentricular tachycardia 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: - ansPulmonary embolism? NOT: tuberculosis A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - ansMorphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - ansA respiratory rate of 8 breaths per minute After a patient completes dialysis, you should anticipate seeing an improvement in which of the following At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currently 60. Which of the following is the most appropriate intervention - ansHave the patient drink 120 ML's of orange juice 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 - ans1520 lab values? - ansNOT: ammonia RELIAS MEDICAL SURGICAL 2 cardiac rhythm - ansV-Tach Cardiac strip - ansSinus rhythm with PAC Cardiac strip - ansUnable to determine Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? - ansDiscarded, then begin the 24 hour collection Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ansWomen could have pain in their arm, neck, back or jaw RELIAS MEDICAL SURGICAL 5 Which of the following issues should be reported up the chain of command - ansA coworker arriving to work under the influence of alcohol Which of the following lab values would you expect to see in a patient diagnosed with?.... - ansLipase - 196 Which of the following medication may cause urine discoloration - ansRifampin 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 - ansRefused to sign for the waste You are providing patient education to a patient prior to administering IV Protonix .... When there is no history of GERD - ansProtonix is given as G.I. prophylaxis to prevent stress ulcers 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? - ansDue 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 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ansThe hospitals language You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide - ansAnd washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff 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? - ansAssess the patient Not: start CPR 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? - ansUpper G.I. bleed You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing: - ansPulmonary embolism interpreter RELIAS MEDICAL SURGICAL 6 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 - ansApply sterile saline soap towels over the extruding site You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ansCanned meats You're providing discharge instructions to a CHF patient. - ansIncrease shortness of breath indicate an emergency? - ansLaryngeal strider RELIAS MEDICAL SURGICAL 7 You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question? - ansAcetylsalicylic acid ( Bauer buffered aspirin) You're reviewing the menu list of a patient on Warfran what food should they not eat? - ansSpinach Your COPD patient is complaining of wheezing and increased shortness of breath - ansAssess your patient for a change in condition Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ansAspirate the fluid, advance the catheter farther, then re-inflate the balloon 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: - ans Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ansPerform a bladder scan 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 Your patient had a TB skin test done on Thursday at 2:45 PM - ansSaturday at 3 PM Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol Your patient was admitted with severe dehydration. Which of the following orders would you question - ansKCI 40 mEq IV push STAT Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter is lying in a supine position. What should be your first response? - ansCall a rapid response is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction RELIAS MEDICAL SURGICAL 10 One of the signs of left sided heart failure is: - ansPulmonary edema NOT: pedal edema Patient 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? - ansEducate the spouse on oxygen use as a medical device in the hospital The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ans4ml The Glasgow, scale ranges from: - ans3 to 15 RELIAS MEDICAL SURGICAL 11 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? - ansHonor the patient's wishes 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? - ansNarcan What information is vital for you to know prior to administering an ordered dose of digoxin - ansHeart rate What is the first sign of increased intracranial pressure? - ansChange in LOC When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - ansSubcutaneous emphysema When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - ansProtecting the patient's head and extremities from contact with surrounding objects When taking care of a patient with pancreatitis, which of the following lab should be reviewed? - ansLipase and amylase Which of the following actions would be considered a violation of Hyppa? - ansLooking through the chart of a coworker admitted to your unit Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - ansMetformin Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy? - ansSputum with streaks of blood NOT: increased salivation Which of the following electrolyte value should be Addressed immediately by the nurse - ansPotassium 2.5 mEq/L Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease? - ansWheat bread RELIAS MEDICAL SURGICAL 12 Which of the following issues should be reported up the chain of command - ansA coworker arriving to work under the influence of alcohol Which of the following lab values would you expect to see in a patient diagnosed with?.... - ansLipase - 196 Which of the following medication may cause urine discoloration - ansRifampin 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 - ansRefused to sign for the waste You are providing patient education to a patient prior to administering IV Protonix .... When there is no history of GERD - ansProtonix is given as G.I. prophylaxis to prevent stress ulcers RELIAS MEDICAL SURGICAL 15 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: - ans Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ansPerform a bladder scan 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 Your patient had a TB skin test done on Thursday at 2:45 PM - ansSaturday at 3 PM Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol Your patient was admitted with severe dehydration. Which of the following orders would you question - ansKCI 40 mEq IV push STAT Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter Correct answer is ventricular fibrillation - ansPaced rhythm - ansSinus tachycardia - ansVentricular tachycardia is lying in a supine position. What should be your first response? - ansCall a rapid response is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction RELIAS MEDICAL SURGICAL 16 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: - ansPulmonary embolism? NOT: tuberculosis A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - ansMorphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - ansA respiratory rate of 8 breaths per minute After a patient completes dialysis, you should anticipate seeing an improvement in which of the following lab values? - ansNOT: ammonia RELIAS MEDICAL SURGICAL 17 At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currently 60. Which of the following is the most appropriate intervention - ansHave the patient drink 120 ML's of orange juice 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 - ans1520 cardiac rhythm - ansV-Tach Cardiac strip - ansSinus rhythm with PAC Cardiac strip - ansUnable to determine Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? - ansDiscarded, then begin the 24 hour collection Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ansWomen could have pain in their arm, neck, back or jaw Heart rate - ans80 One of the signs of left sided heart failure is: - ansPulmonary edema NOT: pedal edema Patient 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? - ansEducate the spouse on oxygen use as a medical device in the hospital The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ans4ml The Glasgow, scale ranges from: - ans3 to 15 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? - ansHonor the patient's wishes RELIAS MEDICAL SURGICAL 20 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? - ansDue 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 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ansThe hospitals language You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide - ansAnd washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff interpreter RELIAS MEDICAL SURGICAL 21 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? - ansAssess the patient Not: start CPR 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? - ansUpper G.I. bleed You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing: - ansPulmonary embolism 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 - ansApply sterile saline soap towels over the extruding site You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ansCanned meats You're providing discharge instructions to a CHF patient. - ansIncrease shortness of breath You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question? - ansAcetylsalicylic acid ( Bauer buffered aspirin) You're reviewing the menu list of a patient on Warfran what food should they not eat? - ansSpinach Your COPD patient is complaining of wheezing and increased shortness of breath - ansAssess your patient for a change in condition Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ansAspirate the fluid, advance the catheter farther, then re-inflate the balloon 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: - ans indicate an emergency? - ansLaryngeal strider RELIAS MEDICAL SURGICAL 22 Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ansPerform a bladder scan 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 Your patient had a TB skin test done on Thursday at 2:45 PM - ansSaturday at 3 PM Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol is lying in a supine position. What should be your first response? - ansCall a rapid response RELIAS MEDICAL SURGICAL 25 Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? - ansDiscarded, then begin the 24 hour collection Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ansWomen could have pain in their arm, neck, back or jaw Heart rate - ans80 One of the signs of left sided heart failure is: - ansPulmonary edema NOT: pedal edema Patient 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? - ansEducate the spouse on oxygen use as a medical device in the hospital The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ans4ml The Glasgow, scale ranges from: - ans3 to 15 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? - ansHonor the patient's wishes 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? - ansNarcan What information is vital for you to know prior to administering an ordered dose of digoxin - ansHeart rate What is the first sign of increased intracranial pressure? - ansChange in LOC When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - ansSubcutaneous emphysema When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - ansProtecting the patient's head and extremities from contact with surrounding objects RELIAS MEDICAL SURGICAL 26 When taking care of a patient with pancreatitis, which of the following lab should be reviewed? - ansLipase and amylase Which of the following actions would be considered a violation of Hyppa? - ansLooking through the chart of a coworker admitted to your unit Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - ansMetformin Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy? - ansSputum with streaks of blood NOT: increased salivation RELIAS MEDICAL SURGICAL 27 Which of the following electrolyte value should be Addressed immediately by the nurse - ansPotassium 2.5 mEq/L Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease? - ansWheat bread Which of the following issues should be reported up the chain of command - ansA coworker arriving to work under the influence of alcohol Which of the following lab values would you expect to see in a patient diagnosed with?.... - ansLipase - 196 Which of the following medication may cause urine discoloration - ansRifampin 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 - ansRefused to sign for the waste You are providing patient education to a patient prior to administering IV Protonix .... When there is no history of GERD - ansProtonix is given as G.I. prophylaxis to prevent stress ulcers 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? - ansDue 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 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ansThe hospitals language You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide - ansAnd washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff 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? - ansAssess the patient interpreter RELIAS MEDICAL SURGICAL 30 Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter Correct answer is ventricular fibrillation is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction RELIAS MEDICAL SURGICAL 31 - ansPaced rhythm - ansSinus tachycardia - ansVentricular tachycardia 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: - ansPulmonary embolism? NOT: tuberculosis A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - ansMorphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - ansA respiratory rate of 8 breaths per minute After a patient completes dialysis, you should anticipate seeing an improvement in which of the following At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currently 60. Which of the following is the most appropriate intervention - ansHave the patient drink 120 ML's of orange juice 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 - ans1520 cardiac rhythm - ansV-Tach Cardiac strip - ansSinus rhythm with PAC Cardiac strip - ansUnable to determine lab values? - ansNOT: ammonia RELIAS MEDICAL SURGICAL 32 Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? - ansDiscarded, then begin the 24 hour collection Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ansWomen could have pain in their arm, neck, back or jaw Heart rate - ans80 One of the signs of left sided heart failure is: - ansPulmonary edema NOT: pedal edema Patient 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? - ansEducate the spouse on oxygen use as a medical device in the hospital RELIAS MEDICAL SURGICAL 35 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 - ansRefused to sign for the waste You are providing patient education to a patient prior to administering IV Protonix .... When there is no history of GERD - ansProtonix is given as G.I. prophylaxis to prevent stress ulcers 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? - ansDue 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 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ansThe hospitals language You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide - ansAnd washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff 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? - ansAssess the patient Not: start CPR 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? - ansUpper G.I. bleed You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing: - ansPulmonary embolism 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 - ansApply sterile saline soap towels over the extruding site You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would interpreter indicate an emergency? - ansLaryngeal strider RELIAS MEDICAL SURGICAL 36 You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ansCanned meats You're providing discharge instructions to a CHF patient. - ansIncrease shortness of breath You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question? - ansAcetylsalicylic acid ( Bauer buffered aspirin) You're reviewing the menu list of a patient on Warfran what food should they not eat? - ansSpinach Your COPD patient is complaining of wheezing and increased shortness of breath - ansAssess your patient for a change in condition RELIAS MEDICAL SURGICAL 37 Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ansAspirate the fluid, advance the catheter farther, then re-inflate the balloon 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: - ans Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ansPerform a bladder scan 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 Your patient had a TB skin test done on Thursday at 2:45 PM - ansSaturday at 3 PM Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol Your patient was admitted with severe dehydration. Which of the following orders would you question - ansKCI 40 mEq IV push STAT Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter Correct answer is ventricular fibrillation - ansPaced rhythm - ansSinus tachycardia is lying in a supine position. What should be your first response? - ansCall a rapid response RELIAS MEDICAL SURGICAL 40 The Glasgow, scale ranges from: - ans3 to 15 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? - ansHonor the patient's wishes 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? - ansNarcan What information is vital for you to know prior to administering an ordered dose of digoxin - ansHeart rate What is the first sign of increased intracranial pressure? - ansChange in LOC RELIAS MEDICAL SURGICAL 41 When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - ansSubcutaneous emphysema When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - ansProtecting the patient's head and extremities from contact with surrounding objects When taking care of a patient with pancreatitis, which of the following lab should be reviewed? - ansLipase and amylase Which of the following actions would be considered a violation of Hyppa? - ansLooking through the chart of a coworker admitted to your unit Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - ansMetformin Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy? - ansSputum with streaks of blood NOT: increased salivation Which of the following electrolyte value should be Addressed immediately by the nurse - ansPotassium 2.5 mEq/L Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease? - ansWheat bread Which of the following issues should be reported up the chain of command - ansA coworker arriving to work under the influence of alcohol Which of the following lab values would you expect to see in a patient diagnosed with?.... - ansLipase - 196 Which of the following medication may cause urine discoloration - ansRifampin 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 - ansRefused to sign for the waste RELIAS MEDICAL SURGICAL 42 You are providing patient education to a patient prior to administering IV Protonix .... When there is no history of GERD - ansProtonix is given as G.I. prophylaxis to prevent stress ulcers 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? - ansDue 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 You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ansThe hospitals language interpreter RELIAS MEDICAL SURGICAL 45 Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol Your patient was admitted with severe dehydration. Which of the following orders would you question - ansKCI 40 mEq IV push STAT Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following - ansNormal sinus rhythm - ansNormal sinus with VTach - ansNot normal sinus rhythm into a flutter Correct answer is ventricular fibrillation - ansPaced rhythm - ansSinus tachycardia - ansVentricular tachycardia 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: - ansPulmonary embolism? NOT: tuberculosis A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - ansMorphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - ansA respiratory rate of 8 breaths per minute is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction RELIAS MEDICAL SURGICAL 46 After a patient completes dialysis, you should anticipate seeing an improvement in which of the following At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currently 60. Which of the following is the most appropriate intervention - ansHave the patient drink 120 ML's of orange juice 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 - ans1520 cardiac rhythm - ansV-Tach Cardiac strip - ansSinus rhythm with PAC lab values? - ansNOT: ammonia RELIAS MEDICAL SURGICAL 47 Cardiac strip - ansUnable to determine Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? - ansDiscarded, then begin the 24 hour collection Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ansWomen could have pain in their arm, neck, back or jaw Heart rate - ans80 One of the signs of left sided heart failure is: - ansPulmonary edema NOT: pedal edema Patient 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? - ansEducate the spouse on oxygen use as a medical device in the hospital The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ans4ml The Glasgow, scale ranges from: - ans3 to 15 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? - ansHonor the patient's wishes 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? - ansNarcan What information is vital for you to know prior to administering an ordered dose of digoxin - ansHeart rate What is the first sign of increased intracranial pressure? - ansChange in LOC When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? - ansSubcutaneous emphysema RELIAS MEDICAL SURGICAL 50 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? - ansAssess the patient Not: start CPR 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? - ansUpper G.I. bleed You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing: - ansPulmonary embolism RELIAS MEDICAL SURGICAL 51 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 - ansApply sterile saline soap towels over the extruding site You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ansCanned meats You're providing discharge instructions to a CHF patient. - ansIncrease shortness of breath You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question? - ansAcetylsalicylic acid ( Bauer buffered aspirin) You're reviewing the menu list of a patient on Warfran what food should they not eat? - ansSpinach Your COPD patient is complaining of wheezing and increased shortness of breath - ansAssess your patient for a change in condition Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ansAspirate the fluid, advance the catheter farther, then re-inflate the balloon 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: - ans Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step? - ansPerform a bladder scan 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 Your patient had a TB skin test done on Thursday at 2:45 PM - ansSaturday at 3 PM Your patient has been diagnosed with a hemorrhagic CVA - ansHeparin infusion per pharmacy protocol indicate an emergency? - ansLaryngeal strider is lying in a supine position. What should be your first response? - ansCall a rapid response RELIAS MEDICAL SURGICAL 52 Your patient was admitted with severe dehydration. Which of the following orders would you question - ansKCI 40 mEq IV push STAT Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action? - ansCompress the drain, then plug the bulb to establish suction